University of Southern California Dissertations and Theses

Effects of a 12-week golf training program on gait and cognition: the Golf Intervention for Veterans Exercise (GIVE) study

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Effects of a 12-week golf training program on gait and cognition: the Golf Intervention for Veterans Exercise (GIVE) study

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Content Running head: GOLF EFFECTS: GAIT & COGNITION

Effects of a 12-week golf training program on gait and cognition: The Golf Intervention for
Veterans Exercise (GIVE) Study

by

Nicole A Marcione

A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(BIOKINESIOLOGY)

December 2019

GOLF EFFECTS: GAIT & COGNITION

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DEDICATION

To all those who have persevered in the pursuit of their dreams, even when they thought it was
impossible.

To my loved ones who have stood by me through these years with their unwaivering support.

To my nephews who have infinite possibilities ahead of them.

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ACKNOWLEDGEMENTS
"If I have seen further it is by standing on the shoulders of Giants."
– Sir Isaac Newton, 1675

Although my name is on this dissertation, it took a village to get to this point in my life.
In the immortal words of Sir Isaac Newton…I, too, have stood on the shoulders of giants, and it
is with the sincerest of heart, full of gratitude, that I acknowledge all of you that have supported
me throughout the years during my time in this doctoral program, and those of you who have
supported me through the decades with your encouragement, love and ever-constant presence in
my life. Completing my doctorate at USC Division of Biokinesiology and Physical Therapy, the
No. 1 rated program in the nation, has been both rewarding and challenging. I have learned more
about myself in the past four years, then I have in the 4 decades of my life. At times I wanted to
give up, didn’t think I belonged, couldn’t imagine why I was taking this journey…and at the
same moment I was so excited to learn, and inspired to discover, and motivated to push myself to
what I thought were impossible limits, which eventually led me to realizing that nothing is
impossible with audacity, courage, hard work, determination, gumption, grace, sweat, tears and,
yes, laughter!
First, I would like to acknowledge my advisor, Dr. George Salem. Thank you for taking a
chance on me. I hardly knew anything about kinesiology, let alone biomechanics, yet you were
still willing to go out on a limb to pick me as your student. The Mentor-Mentee relationship is, if
nothing else, very personal. And, like any relationship, it has its up and downs, and I’m grateful
that you were my advisor over the past four years. Thank you for your guidance. Without your
mentorship, this journey would have been impossible.
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I would also like to acknowledge my dissertation committee members who were so
generous in sharing their expertise with me. Thank you, Dr. Bradley, for all of the time you spent
with me, literally months of weekly meetings, discussing the neural physiology of gait. I so
appreciate our “normal” conversations, outside of the research realm, as well. You provide an
amazing example of a scientist that is both academic and personable, truly being interested in the
well-being of your students. Thank you, Dr. Melrose, for giving so freely of your time and
knowledge of cognitive neuroscience. Without you, I would not have known where to start in the
neuroscience literature; because of your guidance and support, I now have a desire to further my
research in cognition and brain health. Dr. Powers, thank you for sharing your expertise in gait
biomechanics and for always encouraging and challenging me to take my research to a higher-
level. Dr. Walsh, thank you, for being on my guidance committee, your expertise in exercise and
aging was invaluable to me. Along with you being the most incredible teacher that I know, thank
you for modeling what an inspiring and dedicated professor looks like.
A huge thank you to Dr. Gordon, and the Division, for the financial and academic support
provided to me over the past 4 years. I also want to let you know, Dr. Gordon, that your
“Classical Readings in Biokinesiology” was my favorite graduate course during my time at USC.
I feel honored to be one of the few people to have had you as a professor. The faculty and staff in
the Division are always willing and able to help, thank you. An especially big thank you to Raj,
Janet, Lydia and Oshawa who have gone out of their way, more than once, to help me
personally.
Like I mentioned earlier, it takes a village. In my case, that village is full of BKN
students and fellow MBRL lab mates, current and past. Thank you for your help, support, and
motivation. We have celebrated and commiserated together and I will never forget you! Abbi,
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v
Michael, Matt, Moheb, Yo, Jonathan, Jordan and Sara, you are forever in my heart! Andrea D., I
have learned all I know about all things lab-related and golf-related from you. I do not know
what I would have done without you by my side. You are an amazing woman, mother, teacher,
mentor, wife, friend, and all-around one of the best people I know. Thank you for being my
partner-in-crime for the GIVE study. I will cherish our friendship and sisterhood always!
Thank you to all those involved in the GIVE study: Dr. Castle, as the PI, and Erin at the
WLAVA, James Dennerline for teaching our participants to golf, and a huge sense of
indebtedness to all of my participants, both those in the golf training program and those in my
control group. Thank you for donating your time and effort to science. Your dedication to this
project will not be forgotten.
Completing a doctoral program is physically and mentally exhausting, and I want to
thank those who have helped me to stay healthy and sane both in mind and body. Dr. Reyes,
thank you for your support, always helping me to put things in perspective, and keeping my mind
from exploding. Drs. Hong and Kim, and Mercedes, thank you for keeping my body from falling
apart. To all my teachers at The Class by TT: Natalie, Erin, Brenna, Heather, Karly, Jaycee and
Taryn, thank you for your healing method, teaching me to trust myself, and helping me to find
my voice over the past 2.5 years.
I am a true believer in “women-supporting-women”. I am lucky enough to have so many
incredible women in my life and I thank you for always being there for me: Susan, Eloise,
Andrea F., Kristina, Kija, Rachel, Katy, Elizabeth, Diana, Paula, Melanie, Alisa, Amanda,
Hillary, Sarah, Isa, Julia, Donna M, Donna P, Pat Y, Evelyn, Andrea D., Yo and Sara. And to
Ruben, Ian, Eric and John T, you sure know how to help a girl out! Also to all of my Pilates
peeps, students and fellow teachers, and Jay. I love you all.
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I want to thank my family for their support, patience, and love. Dad, Sonny, Tina, Gage
and Cruz, thank you for being in my life. Just think, you won’t be able to ask me “when are you
going to be finished?” anymore. I guess we’ll have to figure out something else to talk about.
Sometimes the family one chooses, extended family, is just as important as one’s blood family.
Susan and David, words cannot express the feelings I have for you. To have your support and
unconditional love means the world to me. I know I will always be fine because you two exist,
and I can count on you no matter what. We’ve gone through many experiences over the years
and shared many adventures. I am forever grateful.
Lastly, the biggest thanks to Marco. You have been my biggest cheerleader, day in and
day out. Thank you for challenging me to be a better person, for being my partner in life, for
your support, motivation, for sharing your fries and ice cream, for making me laugh (even when
I’m crying) and for always believing that I could do it. We did this together! Alright, time to get
this show on the road!

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TABLE OF CONTENTS

DEDICATION .............................................................................................................................. ii
ACKNOWLEDGEMENTS ........................................................................................................ iii
TABLE OF CONTENTS ........................................................................................................... vii
LIST OF TABLES ....................................................................................................................... ix
LIST OF FIGURES ...................................................................................................................... x
ABSTRACT .................................................................................................................................. xi
CHAPTER I OVERVIEW ......................................................................................................... 15
CHAPTER II BACKGROUND & SIGNIFICANCE .............................................................. 18
Statement of the Problem ....................................................................................................... 18
Gait and Aging ........................................................................................................................ 18
Cognition and Aging ............................................................................................................... 21
Revealing Gait and Cognitive Ability Through a Dual-task (DT) Paradigm ................... 22
Summary ...................................................................................................................................... 26
CHAPTER III LITERATURE REVIEW ................................................................................ 28
Introduction ............................................................................................................................. 28
Multimodal Interventions ...................................................................................................... 30
Multicomponent Interventions .............................................................................................. 36
Cognitively-demanding Physical Activity (CPA) Interventions ......................................... 46
CHAPTER IV CHANGES IN OLDER VETERAN’S WALKING PERFORMANCE AND
GAIT MECHANICS FOLLOWING A 12-WEEK GOLF TRAINING PROGRAM: THE
GOLF INTERVENTION FOR VETERANS EXERCISE (GIVE) STUDY ......................... 57
Abstract .................................................................................................................................... 57
Introduction ............................................................................................................................. 58
Methods .................................................................................................................................... 59
Participants ........................................................................................................................... 59
Golf Training Program Intervention .................................................................................... 60
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Activity Levels ....................................................................................................................... 61
Walking Performance and Biomechanics ............................................................................. 61
Data and Statistical Analyses ............................................................................................... 62
Results ...................................................................................................................................... 62
Discussion ................................................................................................................................ 63
CHAPTER V IMPROVEMENTS IN DUAL-TASK PERFORMANCE AND COGNITIVE
FUNCTION FOLLOWING 12 WEEKS OF TRAINING IN A COGNITIVELY-
DEMANDING PHYSICAL ACTIVITY—GOLF ................................................................... 71
Abstract .................................................................................................................................... 71
Introduction ............................................................................................................................. 72
Methods .................................................................................................................................... 76
Experimental Design ............................................................................................................. 76
Recruitment and Screening ................................................................................................... 76
Participants ........................................................................................................................... 77
Golf Intervention Training Program .................................................................................... 78
Testing Procedures ............................................................................................................... 79
Data and Statistical Analyses ............................................................................................... 80
Results ...................................................................................................................................... 82
Discussion ................................................................................................................................ 85
CHAPTER VI SUMMARY & CONCLUSIONS ................................................................... 95
REFERENCES .......................................................................................................................... 100

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LIST OF TABLES

Table 4.1 Golf Intervention for Veterans Exercise (GIVE) Study Inclusion and
Exclusion Criteria.

69
Table 4.2 GIVE Participant Gait Changes from Baseline to Follow-up.

70
Table 4.3 Fast Gait Hip Sagittal Plane Net Joint Moments and Power from Baseline to
Follow-up.

70
Table 5.1 Baseline Demographic Characteristics for Intervention and Control Group.

93
Table 5.2 Dual-task Gait and Cognitive Performance Measures for Intervention and
Control Group.

94

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LIST OF FIGURES

Figure 4.1 Golf Intervention for Veterans Exercise (GIVE) Study Recruitment
Flowchart.

68
Figure 4.2 Sagittal plane net joint power ensemble-average curves during the full gait
cycle (n=10). *significant pre-post difference (p<0.05). Mean ± SD.

68
Figure 5.1 Intervention and Control Group Recruitment Flowchart.

91
Figure 5.2 Pre- and post-intervention changes in dual-task gait and cognitive measures. 92

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ABSTRACT
Gait speed and cognition are important predictors of successful aging. Both slow gait
speed and cognitive decline are associated with poor health outcomes, including hospitalization,
falls, institutionalization and death. Exercise interventions can improve both gait and cognitive
performance in older adults. Together in its entirety, the purpose of this dissertation was to
examine the influence of a 12-week golf intervention on walking performance and cognition in
older adults. Golf training, as a multimodal, cognitively-demanding physical activity, may have
pronounced effects on walking ability and cognition. In the past, studies investigating golf have
typically examined the performance of golfers (fitness, golf swing velocity, ball velocity, upper
and lower-body mechanics during the golf swing) and few have examined the overall functional
and health benefits that come from playing golf (see Chap. III). It is for this reason that we
developed an intervention to safely and effectively teach older adults to become independent
golfers via a 12-week golf training program, which may be an exercise modality that has
pronounced effects on gait and cognition.
Although golfing is commonly viewed as a “recreational activity” and not “exercise”,
recent reports suggest that the physical demands of golf (e.g. navigating the course, walking hilly
terrain, bending over, swinging, weight-shifting) maintain/increase strength, flexibility, power-
production, balance, and aerobic fitness in older adults. Moreover, golf is cognitively
demanding, as evidenced by the preparation, strategizing, measuring, and execution phases of the
game.
The Golf Intervention for Veterans Exercise (GIVE) study was a Phase I, 12-week golf
training intervention study. All participants came to the USC Jacqueline Perry Musculoskeletal
Biomechanics Research Laboratory for baseline testing within 2 weeks of the start of the 12-
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xii
week intervention and returned to the lab within two weeks of the completion of the intervention
for follow-up testing. Those in the intervention group (INT) participated in a 12-week golf
training program (2 x weekly; 90 min per session) with a Professional Golf Association
instructor. There was high adherence to the golf intervention (91%, average: 21.8/24 sessions
attended), none of the participants dropped out the intervention, and there were no study-related
adverse events. The control (CON) group continued to live “life-as-usual”. All participants
completed a six-minute walk test (6MWT), fast single-task gait speed (STGS), fast dual-task gait
speed (DTGS) with a subtraction by 3s task, California Verbal Learning Test 2
nd
edition (CVLT-
II) and National Institute Health Toolbox-Cognition (NIH-C) Battery.
Chapter III is an extensive literature review discussing the latest research examining
multimodal, multicomponent, and cognitively-demanding physical activity interventions that
have assessed gait and/or cognition in older adults with and without physical or cognitive
impairments. Evidence is provided to support the argument that interventions that combine both
physical and cognitive components have added benefits over interventions that only include a
single-type (physical or cognitive) intervention.
The objective of Chapter IV was to answer the research question: Can a 12-week golf
training program improve gait performance, and alter hip joint kinetics in older military
Veterans? Twelve male military Veterans (60-80 years; average: 70.4 ± 4.8yrs) were enrolled in
the GIVE study and completed the intervention. Pre- to post-intervention changes in gait,
including six-minute walk test, single-task fast gait speed, stride length, cadence, sagittal plane
hip joint kinetics were measured. Golf training significantly increased average fast gait speed
(6.7%), stride length (4%), peak hip extensor moment (16.5%) and peak power generation
(46.5%). The 12-week golf training program increased fast gait performance in older military
GOLF EFFECTS: GAIT & COGNITION

xiii
Veterans, as well as increased hip joint kinetics. These changes are likely related to the physical
demands of the 12-week golf program, which included walking the golf course, high-powered
swings and bending/squatting activities.
The purpose of Chapter V was to compare changes in dual-task (DT) gait performance
(maximal/fast gait speed, stride length, cadence), DT cost percentage, episodic memory and fluid
cognition between individuals (n=12) who participated in a 12-week golf training intervention
(INT; 90 min, 2x/week ) and an age-, education- and activity-matched control (CON) group
(n=10). This study was a quasi-experimental design in which participants were not randomly
assigned to groups.
DT performance is often used to examine the relations among mobility, cognition, and
aging, and poor DT performance is associated with increased fall risk and dementia in older
adults. Because golf training requires both physical and cognitive demands to be performed
simultaneously, it was hypothesized that the INT group would demonstrate significantly greater
pre-to-post improvements in DT gait and cognitive performance compared to the CON group.
Two-factor mixed-model ANOVA revealed significant interactions between group and time for
DT gait speed and long-delay episodic memory, and approached significance for DT stride
length, and fluid cognition. Post-hoc paired t-tests revealed significant pre-to-post (p<0.05)
improvements for DT fast gait speed (9.8%), DT stride length (4.3%), long-delay episodic
memory (45.8%), and fluid cognition (15.3%). There were no pre-to-post changes in the CON
group. The effect sizes for above variables were large (η
2
=0.18-0.31), suggesting that there was a
golf training effect on DT gait and cognitive performance. The combined demands of golf, with
their effects on neuroplasticity, may be the drivers behind the improvements demonstrated by the
intervention group. This study’s results are supported by existing evidence suggesting that
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xiv
simultaneous physical and cognitive training may be more beneficial in improving DT
performance and cognitive function than physical or cognitive training alone. These findings
indicate that participation in a 12-week golf training program improves DT gait and cognitive
performance in older adults and that golf may be considered a multimodal, cognitively-
demanding physical activity.
These studies demonstrate that participation in a 12-week golf training program golf is
safe, feasible, and effective in improving gait and cognitive performance in older adults. While
there were limitations such as a non-randomized control group and small sample size, the large
effect sizes observed, along with significant improvements in our intervention participants,
reflect meaningful changes that attest to the overall health benefits of golf training. The high
adherence level (91%) gives us insight into how our participants valued and enjoyed the
intervention. These results provide evidence that golf, as a multimodal, cognitively-demanding
physical activity, may improve physical and cognitive function, leading to attenuated risk for
poor health outcomes, maintained independence and improved quality of life.

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CHAPTER I
OVERVIEW

Gait speed and cognitive function are important predictors of successful aging. Age-
related slowing gait speed and cognitive decline are both associated with poor health outcomes in
later life and an increased risk for falls, institutionalization, hospitalization, dementia, and
mortality (1–7). There is a robust literature demonstrating that exercise and physical activity
have important roles in maintaining, and improving, both physical and cognitive function of
older adults (8,9,18,10–17). In particular, multimodal, cognitively-demanding exercise
interventions that include components of strength, endurance, flexibility, balance, coordination,
strategy and attention have improved gait and cognitive abilities in older adults (18–20). Golf
training may have pronounced effects on walking ability and cognition (21–26). Previous studies
investigating golf have typically focused on the performance of golfers and only a handful have
investigated the overall functional and health benefits that come from playing golf (24–27). It is
for this reason that we developed an intervention to examine a 12-week golf training program as
an exercise modality that may have pronounced effects on gait and cognition. Although golfing
is commonly viewed as a “recreational activity” and not “exercise”, recent reports suggest that
the physical demands of golf (e.g. navigating the course, walking hilly terrain, bending over,
swinging, weight-shifting) preserve/increase strength, flexibility, power-production, balance, and
cardiorespiratory fitness in older adults (21,22,28). Moreover, golf is cognitively demanding, as
evidenced by the preparation, strategizing, measuring, and execution phases of the game
(23,24,29). This study deepens our understanding on how golf, as a cognitively demanding
exercise, can impact gait and cognition; thus, perhaps resulting in reduced future risk for poor
health outcomes. This study will inform the development of cognitively-demanding physical
GOLF EFFECTS: GAIT & COGNITION

16
activity programs designed to keep older adults independent, able to “age in place”, and improve
everyday function and quality of life. The general objective of this dissertation is to examine the
cognitive and gait adaptations that occur following participation in a 12-week golf training
program for older adults. The general hypotheses are 1) the physical and cognitive demands of a
12-week golf training program will improve single-task and dual-task fast gait performance and
2) the physical and cognitive demands of a 12-week golf training program will improve
cognitive performance.

Specific Aim 1: To quantify changes in single-task fast gait performance and hip kinetics
following a 12-week golf training program (Chapter IV).
Hypothesis 1.1: After completing the 12-week golf training program, participants will
demonstrate significant increases in six-minute walk test.
Hypothesis 1.2: After completing the 12-week golf training program, participants will
demonstrate significant increases in laboratory fast gait speed.
Hypothesis 1.3: After completing the 12-week golf training program, participants will
demonstrate significant increases in stride length, but not cadence.
Hypothesis 1.4: After completing the 12-week golf training program, participants will
demonstrate increased peak hip extensor moments and peak hip power generation.

Specific Aim 2: To compare changes in dual-task fast gait performance between individuals in
the intervention group and those in the control group (Chapter V).
Hypothesis 2.1: Intervention group changes in fast dual-task gait speed will be greater
than changes of fast dual-task gait speed in the control group.
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Hypothesis 2.2: Intervention group changes in fast dual-task gait stride length will be
greater than changes of fast dual-task gait stride length in the control group.

Specific Aim 3: To compare changes in cognitive performance between individuals who have
participated in a 12-week golf training program and those in the control group (Chapter V).
Hypothesis 3.1: Intervention group changes in episodic memory scores will be greater
than changes in episodic memory scores in the control group.
Hypothesis 3.2: Intervention group changes in fluid cognition scores will be greater than
changes in fluid cognition scores in the control group.

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CHAPTER II
BACKGROUND & SIGNIFICANCE
Statement of the Problem
Gait speed and cognitive function are critical factors for optimal aging. Age-related
slowing gait speed and cognitive decline are associated with poor health outcomes in later life
and an increased risk for falls, institutionalization, hospitalization, dementia, and mortality (1–4).
It is projected that by 2050, there will be 88 million Americans over the age of 65 (30,31); 35%
of them will have at least one fall annually and it is estimated that 14 million will develop
Alzheimer’s Disease (1,32). The costs associated with falls in 2014 was $31 billion (cdc.gov)
and dementia costs could be as high as $1.1 trillion (alz.org) by 2050. In an aging population,
maintaining walking ability and cognitive faculties are essential to reduce fall risk and stay
independent and active in the community. There is a robust literature demonstrating that exercise
and physical activity have important roles in both the physical and cognitive function of older
adults (see Chap. III).
Gait and Aging
Slowing gait speed and gait ability impairments accompany the aging process. The
relations among aging, gait speed and physical function is so salient, that gait speed has been
called a "sixth vital sign"; listed along with other critical vital signs such as blood pressure and
heart rate (2,33,34). With aging, decreased walking speed is associated with poorer health
outcomes, disability, hospitalization, increased fall risk, cognitive decline, and mortality
(2,3,33,35,36). Because of its relatively low cost and ease of implementation, measuring gait
speed has been recommended as a potentially useful clinical indicator of general health, physical
function and wellbeing (35). Slowing gait speed and decreased mobility could rapidly lead to a
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19
downward spiral of reduced physical activity, social engagement and cognitive function, which
has a direct effect on health and survival in older adults (3). A change in gait speed of ±0.1m/s is
an established minimally clinically-important difference (MCID). MCIDs are defined as "the
smallest difference in the score that is considered worthwhile or important" (37).
While much of the gait speed literature only looks at self-selected or "normal" gait speed,
it has been suggested that fast or maximal gait speed is another important indicator of physical
function and overall health (2,38). Maximal walking speed can provide the clinician or
researcher with pertinent information regarding functional capabilities of an older adult in the
community; such as crossing the street safely and quickly, catching a bus, or moving out of the
way of an unexpected vehicle. As an example, in the United States, a person needs to walk at a
speed of 1.32 m/s or faster to safely cross the street (2,39,40). So, it is noteworthy to not only
utilize self-selected gait speed when assessing older adults' physical abilities, but to also measure
fast/ maximal gait speed. The reliability and sensitivity to change of these gait measures is well
established; this includes measurements made with a stopwatch, using a Gaitrite (pressurized
mat) or using high speed motion capture systems (41–44). Fast gait assessments in older adults
are important because they may be a more sensitive measure of overall physical and cognitive
function when compared to changes in self-selected gait. There is a higher demand of attention
and executive control at faster gait speeds (45) and these executive and attentional demands are
revealed in changes in the activity of areas that comprise the prefrontal and parietal cortices,
along with the cerebellum and the basal ganglia (Bostan, Dum, & Strick, 2013; Yogev et al.,
2005; Yogev, Hausdorff, & Giladi, 2008). Fronto-parietal networks, along with fronto-striatal
networks, play important roles in both motor and cognitive behavior (47,49–51).
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20
Typical biomechanical markers of gait dysfunction include, not only decreased gait
speed, but also shorter steps/strides and increased cadence (steps per minute) (52). Gait speed is
determined by these two factors: stride length and cadence. In general, older adults exhibit higher
cadence than young adults; and this faster cadence in older adults remains intact regardless of
speed changes, meaning that their cadence remains similar in both self-selected and maximal gait
speed (52). Therefore, typical changes in older adults' gait speed, when faster gait is required, are
usually due to changes in stride length (52–54). These age-related changes in stride length are
attributed to a loss of plantarflexor (PF) strength and PF power generating capacity (55–60). One
major difference seen between young and older adults is that, in older adults, there is a distal to
proximal shift of power output of the lower-extremity joints (60–63). This shift means that the
hip joint, by increasing power output, may have the capacity to compensate for the distal age-
related weakness of the plantarflexor muscles (64,65). Older adults rely less on the ankle joint
musculature and place more emphasis on the hip joint musculature to compensate for the age-
related loss of ankle plantarflexor strength (52,59,60,62,64,65). The golf swing, along with
picking up a golf ball require large hip demands (66,67). Thus, golf training, via increased hip
demands, may be a stimulus for improved fast gait performance in older adults after participation
in a 12-week golf intervention. Some underlying biomechanical, physiological, and
neuromuscular mechanisms of decreased gait performance are decreased muscular strength,
increased energy costs, less support of body weight during stance phase to maintain upright
balance, decreased oxygen consumption and metabolic rate, decrease in the fast conducting
neurons, decrease drive of corticospinal pathways, poor signal conduction of motor neurons, and
the fact that large diameter motor neurons are more susceptible to the aging process (57,64).
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21
Cognition and Aging
Cognitive function is another important predictor of successful, independent aging. It
plays a key role in regulating walking (36). Two very critical components of cognitive function
are executive control and memory. The structural and functional areas of the brain that are
responsible for these two components are especially vulnerable to age-related decline (47). The
prefrontal cortex, the anterior cingulate cortex, the supplementary motor area, premotor cortex,
posterior parietal cortex, basal ganglia, and the cerebellum have all been implicated in both
motor and non-motor/cognitive function (49,51,68–72). White matter tracts, connecting these
structures, are also vulnerable to the aging process. White matter lesions (aka, white matter
hyper-intensities) or loss of white matter volume result in poor signal conduction, compromised
axonal integrity, and demyelination, which in turn are likely responsible for slowing behavior
(physical and cognitive) and a less efficient transmission of neural signals (73). Many neural
correlates that involve the cognitive control of posture and gait overlap with the cognitive
functions of executive control, attention, inhibition and working memory (74,75). As mentioned
above, fronto-parietal networks, along with fronto-striatal networks, play important roles in both
motor and cognitive behavior (47,49–51). Increases in motor activity may directly enhance
cognitive neural connections between locomotor regions in the brainstem, and cortical and
subcortical regions of the brain resulting in improved gait and cognition (74,76–78). Physical
and motor fitness, which includes balance, agility, coordination, and flexibility, have been
directly related to improvements in cognitive tasks that demand attention and information
processing (79–83). Neuromuscular factors of physical activity may have an impact on cognition
through maintenance of fast conducting neurons (via gray and white matter volume), delaying
the onset of decreased drive of corticospinal pathways, maintaining signal conduction of motor
GOLF EFFECTS: GAIT & COGNITION

22
neurons (through intact white matter), and by attenuating the loss of large diameter motor
neurons that are more susceptible to the aging process (57,64,84–86).
Age-related cognitive decline is not dependent on genetics alone, it is also dependent on
lifestyle factors such as physical activity levels, exercise, diet, alcohol consumption and
smoking. Increasing physical activity, and incorporating healthy lifestyle changes, in later life
can influence the rate of cognitive decline that accompanies the aging process (87,88).
Epidemiological studies have shown an association between physical activity and brain health
(89). Previous research demonstrates that physical activity interventions may improve cognitive
function in older adults (8–10,12,13,18,23,79,90,91). Most of the evidence has utilized exercise
interventions that incorporate treadmill, cycling or weight lifting; repetitive exercises that are not
associated with large cognitive demands. Fewer studies exist that examine physical activities that
are more cognitively demanding, such as tai chi, yoga, dance, boxing, surfing, tennis or golf
(23,24,29,90,92–97). What is a cognitively-demanding physical activity? This type of activity
requires attention to environmental stimuli (i.e. a partner, uneven surfaces, wind and other
weather conditions), learning through feedback (both internal and external feedback), novel and
challenging tasks, the need to maintain motivation, and engaging individuals to become
consciously aware of their movements and breathing patterns, that may bring an amount of
mindfulness to the activity (29).
Revealing Gait and Cognitive Ability Through a Dual-task (DT) Paradigm
Activities of daily living often require walking while performing multiple concurrent
tasks (multi-tasking). Dual-task (DT) paradigms are used to examine the relationship among
mobility, cognition, and aging. One DT paradigm that is commonly used to explore this
relationship is combining gait with a cognitive task (98). In DT paradigms, there is a "cost"
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23
associated with both the motor and cognitive tasks being performed at the same time. This DT
interference happens when two different tasks are simultaneously performed which usually
results in poorer performance ("cost"), in one or both tasks (99). Two primary areas that are
implicated in DT performance are the prefrontal cortex and parietal cortex, which make up the
fronto-parietal network (68). This network is thought to be a central coordinator of complex
cognitive processing (69,100). Evidence demonstrates that there is an increase in activity in this
network due to the higher attentional demands of a DT paradigm, increased cognitive
requirements, and larger loads (both cognitive and physical) requiring the coordination of
interfering processes of attention, working memory, task ordering, and task switching (70,100–
103).
In older adults, the addition of a dual-task significantly reduces gait speed (104). Reduced
DT performance and impaired executive function are associated with an increased fall risk and,
compared to single-task gait performance, DT performance is a stronger predictor of future falls
in community-dwelling older adults (105). Larger effects of exercise are seen on DT gait speed
compared to single-task gait speed (11,106–109). Exercise interventions can increase DT gait
speed and decrease DT cost, resulting in attenuated risk for poor health outcomes (11,36).
Calculating DT cost is another way to gain insight into this relationship between mobility,
cognition, and aging. While DT gait speed only examines DT capability, DT cost takes into
consideration the single-task performance compared to the DT performance ((single-task - dual-
task)/single-task x 100) and creates a percentage of this ratio. Although, there are no established
MCIDs for DT cost, in a recent 2017 JAMA article, Montero-Odasso et al. (103) demonstrated
that a DT cost of 20 percent and higher was associated with dementia.
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Will we observe improved changes in fast gait, DT fast gait and cognitive function after a
12-week golf training program? This study is one of the few to examine golf from a health and
wellness perspective (24–27), and not from a golf performance perspective (110). With the
current 12-week comprehensive intervention, we hypothesized improved physical, cognitive and
DT performance, based on improved neurological and biomechanical functioning, driven by the
demands of golf training. Golf is typically thought of as a leisure time activity, and not as a form
of therapeutic exercise; however, golf training simultaneously combines physical and cognitive
demands (21,72). Physical demands include walking on uneven terrain, walking up steep hills on
the golf course, picking up a golf ball, pulling a cart with clubs, high-powered golf swings with
controlled momentum, and navigating obstacles (gopher holes, woody areas with branches and
leaves, sand traps, and soggy/muddy grassy areas). Cognitive demands include determining the
intensity of the swing (tee-off vs. putting), deciding which club to use for each shot, finding the
ball after it has been hit, incorporating internal feedback from the last shot to improve the next
shot, incorporating external feedback from the instructor on what changes are needed to
accomplish the goal, "reading" the green, reward-based association with what a "good" shot
feels/sounds like, focusing all attention on the ball and tuning out all other distractions (cars,
helicopters, birds, fellow players talking), paying attention to environmental conditions (wind,
weather, the type of grass).
Chapter IV aims to establish if the completion of a 12-week golf training program
intervention, comprised of 2, 90-minute sessions per week, will result in participants’ improved
fast gait performance (six-minute walk, gait speed, and stride length). We hypothesize that
improvements in gait performance will be due to increased peak hip extensor moments and peak
hip power generation because gait speed is dependent on stride length and cadence. Older adults
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25
tend to maintain cadence but adjust their stride length in order to meet the demands of increased
gait speed (64). Stride length can be influenced by lower-extremity ROM and joint force
production. Older adults utilize increased hip joint kinetics to compensate for ankle joint deficits
(60,62,63). Two major components of the golf game that affect hip joint musculature and force
production are the golf swing and the lunges/squats used to tee-up, mark the golf ball or pick up
the golf ball. Swinging a golf club and performing lunges/squats have similar hip joint loading
demands, which produce large hip extensor and flexor moments in the sagittal plane (66,67).
As mentioned above, DT paradigms are used to examine the relationship among mobility,
cognition, and aging. Chapter V presents both DT gait and cognitive performance measures. The
DT paradigm utilized was fast walking with a serial subtraction by 3's task. This paradigm
measures how a cognitive load affects gait speed. An arithmetic task, added to a gait task, relies
on working memory (the need to remember to perform both tasks simultaneously), divided
attention and planning, all happening concurrently, creating a high demand of the executive
control of the participant (111). This DT measure necessitates higher attentional demands and
increased cognitive loads requiring the coordination of interfering processes of attention,
working memory, task ordering, and task switching (70,100–102). With all the motor activity
and cognitive demands that occur during golf training sessions, it is reasonable to assume that
this training would have a direct impact on the neural areas related to gait and cognition.
Preliminary findings in our work suggest that the golf training program improves fluid cognition
and episodic memory (31). These results are not surprising, given the amounts of focus, attention
and memory that are required on the golf course. A golfer must remember their score and their
opponents' scores, where the ball landed, and to incorporate the internal (body awareness of a
good vs. a bad shot) and external feedback (instruction given from the golf pro). The large
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26
amount of focus and attention it takes to hit a small golf ball hundreds of yards, over and over
again, may lead to improved processing in the orienting and executive control attentional
systems (112). A golfer makes thousands of decisions and receives many avenues of feedback
(internal and external) that could drive changes in the prefrontal cortex and posterior parietal
cortex, which make up the fronto-parietal network. The cerebellum is also constantly being
utilized, not only to coordinate movements but also to integrate motor and non-motor
information. These cognitive improvements may be a direct result of increased activity and
reinforced non-motor connections between the motor regions, the basal ganglia, prefrontal
cortex, posterior parietal cortex, cerebellum and limbic system of the brain (113–116). Thus, we
hypothesize that those who complete the 12-week golf training program will have greater
changes in cognitive performance than those in the control group.

Summary
Gait speed and cognitive function tend to decline with aging. Both are risk factors for
falls, hospitalization, dementia and mortality. Through improved neurological and physiological
functioning, delayed onset of these declines may result in improving risk factors for poor health
outcomes. There is ample evidence in the literature that exercise interventions improve both gait
ability and cognitive function in older adults, as will be reviewed in the next chapter. With this
project, it is our intention to establish golf as a cognitively-demanding physical activity, and to
provide evidence that participation in a 12-week golf training program may improve gait and
cognitive performance in older adults through attenuating the declines in gait speed, DT
performance and cognition that typically accompany aging. Findings from this dissertation will
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27
inform the future development of cognitively-demanding physical activity programs to improve
everyday physical and cognitive function and quality of life in older adults.
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CHAPTER III
LITERATURE REVIEW

Introduction
Exercise is proposed to be a “poly-pill”, capable of improving both physical and
cognitive function in older adults (87). For decades, it has been known that physical activity
and/or exercise training improves physical function in later life (117,118). Physical fitness
programs including aerobic, strength, balance, flexibility, coordination, functional and gait
training, have all been recommended for optimal aging in order to maintain mobility, stay
independent in the community, and reduce risk for disability, falls, dementia and hospitalization
(117–119). Around the turn of this century, evidence emerged that physical activity not only
improved physical performance in older adults, but was associated with cognitive performance
as well (85,120). After this revelation, there was an explosion of studies investigating various
types of exercises and their effects on physical and cognitive function (6,15,123–125,16–
18,81,82,99,121,122). There have also been studies demonstrating that this association is
bidirectional, in that cognitive interventions can improve physical performance (126,127),
further establishing that there is a mind-body connection, where the brain affects the body, and
body affects the brain. There is no lack of evidence that aerobic training, resistance training, and
cognitive training improve physical and cognitive function, however if various types of trainings
were combined would the improved outcomes potentially be even greater than those trainings
that only consisted of one type of training? Can a multifactorial training which includes cognitive
demands in addition to physical demands (sequentially or simultaneously), be more effective in
improving physical and cognitive functioning than single-task (ST) type of training (124,128)?
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In the past 5 years, the number of studies examining multiple types of training on
physical and cognitive performance have increased exponentially (18,129). As mentioned above,
traditional forms of exercise may include components of aerobic, strength, balance, flexibility,
coordination, functional and gait training. Multifaceted interventions, which incorporate multiple
exercise components and/or include additional cognitive challenges, appear to have additive
performance benefits over physical or cognitive training alone (18,20,29,90,130–133). Currently,
there are 3 ways that “multimodal” or “multicomponent” (oftentimes interchanged) exercise has
been operationalized in this field of research. First, and the most commonly used method, is an
exercise activity that combines multiple physical fitness components as described by the Physical
Activity Guidelines, published by the US government (health.gov/paguidelines/second-edition).
According to these guidelines, “multimodal” physical activities incorporate a combination of
aerobic, strength, balance, coordination, flexibility and speed of movement components. The
second example are those studies that have combined a physical training activity with a separate
cognitive training paradigm into one intervention. This type of intervention has been called both
“multimodal” and “multicomponent” (18,130) Lastly, there are exercise interventions that have a
simultaneous/concomitant physical and cognitive component within them. These types of
interventions have been termed: “multimodal” (129), “dual-task (DT) intervention” (18,20),
“multicomponent cognitive-physical training” (18), “cognitive-motor intervention” (133),
“gross-motor cognitive training” and “multi-domain mind-body practice” (19), to name a few.
Certain physical activities are considered inherently both physically and cognitively demanding;
these include tai chi, yoga, dancing, boxing, surfing, tennis and golf
(23,24,96,97,108,129,130,134–138,25,139–148,26,27,29,53,90,93,95); these types of activities
could be referred to as cognitively-demanding physical activities. For the purpose of this
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30
dissertation, our operational definition of these terms will be 1) multimodal: a combination of
two or more traditional types of exercise/physical activity (i.e. aerobic with strength and balance
training). 2) multicomponent: a combination of a physical training activity with a sequential or
simultaneous cognitive training paradigm in one intervention (i.e. walking on a treadmill while
playing a card game), and 3) cognitively-demanding physical activities: include physical
activities which inherently combine cognitive demands that require attention to environmental
stimuli (i.e. a partner, uneven surfaces, wind and other weather conditions), include learning
through feedback (both internal and external), incorporate novel and challenging tasks, entail a
conscious awareness of movements and breathing patterns, and involve mindful movements (not
simply relying on the automaticity of a movement) (29).
Multimodal Interventions
There is much evidence acknowledging the benefits of multimodal interventions for
improving gait, cognition and overall fitness (130,149,150). In years past, the American Heart
Association and the American College of Sports Medicine, and more recently the updated 2018
US ODPHP Physical Activity Guidelines for Americans (health.gov/paguidelines/second-
edition) (28,118,151) have recommended interventions that include a combination of balance,
muscle-strengthening, cardiorespiratory/aerobic activity, coordination and speed of movement,
for older adults. In this section I will review multimodal (MM) interventions that included gait,
cognitive, or both types of outcome measures.
A 16-week RCT (152) investigated a MM (aerobic, strength, balance) vs. resistance
training (RT) intervention in 69 sedentary older adults aged 80+. This group found that there
were no significant differences between groups in cognitive measures of global cognition test,
naming or attention tests. They conclude that this may be due to a poor adherence rate,
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31
particularly in the MM group, and that perhaps those who are 80+ years old may need longer
intervention durations than 16 weeks to be effective in this population.
A 6-month, pre-post study examined how a MM (aerobic, strength, balance and posture)
affected 7 patients with Alzheimer’s disease (153). Measures included 8-ft Timed Up-and-Go
(TUG), activities of daily living and overall cognitive function using the Alzheimer’s Disease
Assessment Scale – Cognitive (ADAS-Cog). Patients significantly improved their TUG and
functional capacity scores, but not the ADAS-Cog measure. In this population, with progressive
neuro-degeneration, maintaining cognition levels (which was observed) is considered a positive
outcome regardless of significant improvements.
A large, 12-week RCT (154) of 298 community-dwelling older adults (65+) examined
how a MM (aerobic, strength, coordination, and stretching) intervention vs. usual-care control
could affect gait. Intervention participants had significant improvements in both six-minute walk
test (6MWT) (20.6m) and ST self-selected gait speed (0.05m/s) compared to no changes in
control group. The average age of the intervention group was 79.6 +/-8.2, considering this,
maintaining gait speed, let alone increasing it, is a positive outcome.
Twenty-four nonagenarians (90+) were randomized into either a MM (power training,
balance and gait training) or stretching control group for a 12-week intervention (155). ST and
DT gait speed did not change in the intervention group, however the control groups’ gait speed
for both ST and DT significantly decreased (0.08m/s and 0.07m/s respectively), again
reinforcing the importance of these interventions in maintaining performance and attenuating
typical age-related declines seen in this population.
A 6-month quasi-experimental intervention study (156) aimed to investigate if
participation in a MM (functional exercise, walking and balance training) program would affect
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32
self-selected and fast gait speed and TUG-Cog in 99 osteoarthritis patients, aged 60 and older.
Participants were divided into two groups depending on whether or not they had normal blood
pressure (NTS) or controlled hypertension (HTS). Self-selected gait speed improved
significantly by 10.6% only in the hypertension group, while fast gait significantly improved in
both groups by 70.7% (NTS) and 71.4% (HTS) with very large effects sizes of 2.75 and 3.81,
respectively. There were no TUG-Cog changes in either group. Interestingly, the authors do not
comment on the reason for such large changes in fast gait speed. However, some of the
functional exercises used in the intervention targeted hip musculature: chair sit-to-stands and
picking up a weight from the floor. Improved hip strength and function may translate into faster
maximal gait speeds (62,65,157), as we will observe in Chapter IV of this dissertation.
A 4-month pre-post study (158) of 67 community-dwelling adults categorized as “fallers”
(aged 64+) examined the effects of a MM (strength and power, coordination, agility, flexibility)
intervention on physical performance including self-selected gait speed. After the 4 months,
participants increased gait speed by 0.17m/s which was both statistically and clinically
significant (>0.10m/s). Importantly, at a 6-month follow-up, there was a reduction in the average
number of falls from 3 per year to 0 in 6 months, reducing the absolute fall risk by 34%. They
conclude that a MM approach is effective at addressing the physical requirements needed
attenuate the risk of falls in a population at high risk for falling.
Halvarsson, etal. (107) found in 69 community-dwelling adults with osteoporosis (aged
65+) that those in both balance training (exercises targeting postural control) and balance
training + walking significantly increased their ST and DT gait speed for both self-selected and
fast gait speeds after 12 weeks, when compared to the control group. Both groups also had a
clinically meaningful increase in fast ST and self-selected DT gait speeds (>0.10m/s) after the
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intervention. They also improved their fall-related self-efficacy and balance scores. The same
researchers (159), in an earlier 2011 study in 59 participants (65+) with the tendency to fall,
found that a 12-week multimodal balance training program improved ST fast gait speed and
cadence, and decreased the likelihood of depression. The gait speed increases observed in fast,
but not self-selected may reflect an increased maximum available capacity/physical reserve
needed in daily life, which is important for interacting in one’s environment.
A large, 12-week RCT (160) of 217 community-dwelling pre-frail adults (aged 65+)
investigated how a MM (strength and functional training) intervention affected TUG and
6MWT. Participants significantly improved both TUG (p<0.01) and 6MWT (p<0.001), 6MWT
increased by 33.5m, which is considered a small clinically meaningful change. These
improvements were maintained a 6-month follow-up.
A 6-week quasi-experimental study (161) included 20 frail, institutionalized adults
ranging from 77-95 years old. The MM intervention consisted of power and HIIT training, while
controls had usual care. Fast gait speed and 6MWT both significantly improved by 25% and 19%
respectively, controls did not improve. Researches posit that the high intensity of the MM
exercises may be a reason for the observed increases in such a short amount of time.
A 12-week RCT (162) investigated the effects of a MM (aerobic, strength, agility and
coordination) training program vs control group on gait performance in 26 community-dwelling
adults (65+). MM group increased their self-selected gait speed by 15% and TUG by 17%, this
was likely due to increased peak ankle extensor torque (18.8%). This study provides evidence
that a MM training program, which emphasizes high-speed movements at the ankle joint, is
effective in improving gait speed.
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A 3-month RCT study (163) included 61 residents with mild to moderate dementia (mean
age: 81.9 years). MM intervention participants performed progressive resistance and functional
training during the 3 months. The intervention improved fast gait speed (12.5%), stride length
(7.1%) and cadence (6.0%). Trainings such as these are promising for this population, who often
feel that physical declines are intractable, since those who had lower functional status at baseline
had a better response to the intervention.
One hundred community-dwelling, frail, sedentary older adults (aged 70+) participated in
a 24-week RCT (164) investigating the effects of a MM (aerobic, strength, proprioception, and
stretching) exercise intervention on cognitive and physical functioning. The intervention group
improved in their Tinetti gait test score by 4.3% and their global cognition score, as measured by
the MMSE, by 9.1%. They found that 31.4% of the intervention group had reversed their frailty
diagnosis after the 24 weeks.
A 16-week RCT (165), with 49 community-dwelling women (aged 65-75) investigated a
MM (aerobic, strength, and motor fitness) intervention’s effects on TUG, 6MWT, and cognitive
measures (processing speed, executive control, attention/inhibition, reaction time and working
memory). The intervention participants improved their TUG (25%), 6MWT (19.5%). All
cognitive assessments improved with moderate to large effect sizes, except working memory and
reaction time. These tests were administered as a computer-based test, and the authors posit that
maybe the participants were not comfortable using this type of technology and this may have
influenced their scores.
A 3-month quasi-experimental study (166) with 31 care facility residents, autonomous
women (aged 75+) examined the effects of a MM intervention (walking, strength, and stretching)
on physical and cognitive function. 6MWT improved by 29.8% and was, in addition to
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35
statistically significant, also clinically meaningful with an improvement of more than 50m. All
cognitive assessments (attention, memory, processing speed, executive control, inhibition, and
logical memory) significantly improved after the 3 month intervention, compared to no change in
controls. They also observed significant increases in Brain-derived neurotrophic factor (BDNF)
levels, which may be one of the driving factors behind the improvements demonstrated, thus,
encouraging future studies to include this measure in varied older populations.
Twenty-nine community-dwelling 65+ adults participated in a quasi-experimental study
(167) using a MM intervention (endurance, resistance, and balance training). 6MWT, self-
selected and fast gait speed, and stride length for both self-selected and fast improved (p<0.001).
Increases in all 6 gait measures were also clinically meaningful (6MWT: >50m, gait speed:
>0.10m/s, stride length: >0.05m). The authors posit that the high intensity of the MM
intervention may be the reason for the large effect sized observed in the participants’ gait
performance.
A 12-week quasi-experimental MM intervention (endurance, resistance, and balance
training) included 27 community-dwelling 65+ adults (168). DT gait performance and executive
function were the main outcome measures. Gait was assessed under two types of DT conditions:
serial subtraction by 7s and naming animals. Intervention participants improved (statistically and
clinically) gait performance in both conditions in gait speed (serial subtraction: 27.0%, animal
naming: 29.5%) and stride length (serial subtraction: 12.2%, animal naming: 11.7%). Executive
function improved and this improvement was significantly and strongly correlated with each dual
task outcome. The authors stress the importance of the beneficial effect of exercise on DT
performance to carry out daily activities of living in this older population.
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36
An 8-week RCT using a MM (endurance, resistance, balance, and coordination) exercise
program (169) included patients with colorectal cancer and chemotherapy-induced peripheral
neuropathy. By the end of the intervention, participants improved their 6MWT distance by
41.4m, increasing their endurance levels. This is an important improvement, as cardiorespiratory
fitness can allow for more independence and aging in place for this population.
In summary, there is strong evidence that MM interventions can improve both gait and
cognitive performance in various populations of older adults, including those who are healthy, are
frail, have osteoporosis, cancer, mild cognitive impairment (MCI) and dementia. These
improvements were observed in interventions that varied in length from six weeks to six months.
The most common combination of components was that of endurance, resistance, and balance,
however it was interesting to see that HIIT-type exercise improved performance in those on the
higher-end of the age spectrum (nonagenarians) and even those who living in institutions. Some
may avoid implementing a HIIT or power training protocol in theses populations, due to the nature
of their high intensity, but these studies give evidence that this high-intensity training is feasible
and may be a useful addition to MM interventions. Next, we will consider those studies that include
both components of physical exercise and cognitive training in the same intervention.
Multicomponent Interventions
Multicomponent (MC) interventions are a combination of a physical training activity with either
a sequential or simultaneous cognitive training paradigm in a single intervention. It has been
argued that this type of combined training may be more effective in improving physical and
cognitive functioning than any one type of training on its own (13,123,124).
A 24-week RCT (170) examined the effect of a MC intervention (MM + Mind-Motor
training) vs. a MM (aerobic, strength, balance, flexibility) alone control group on cardiovascular
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37
health and fitness. One hundred twenty-seven community dwelling adults (67.5 avg. age) were
assessed at 24 weeks and a 52-week follow-up. This study assessed cardiovascular outcomes, not
gait or cognition. Researchers found that there were no differences between the two groups in
any of the study’s cardiovascular outcomes. Both groups improved, and the addition of a
cognitive component did not result in additional benefits to cardiovascular health.
An 18-week quasi-experimental study (171) investigated a MC intervention (functional
exercises with mindfulness and breathing exercises) vs. life-as-usual control group in 12
participants (avg. age 84.4 yrs) with dementia. The findings were that the intervention had a
small effect size on TUG performance (0.34), but a med-large effect size (0.76) on global
cognition. The study was designed to emphasize procedural learning, using a similar structure for
each session. An extremely interesting observation from this study was that even when
participants did not remember that they had been in the class before, their bodies were able to
remember which movements came next in the sequence, reinforcing that motor learning can
bypass the hippocampus and other brain areas that are typically responsible for learning and
memory.
An 8-week RCT (172) with 28 adults diagnosed with mild-to-moderate dementia were
randomized into either a music dual-task training (MDTT) intervention group or a control group
(MC) that combined walking with cognitive tasks (playing chess). They assessed processing
speed, as well as ST and DT gait. The MDTT group improved their processing speed by almost
an entire minute on average (from 285.7s to 228.1s to complete the TMTA). There were no
differences between groups for ST gait speed, however there was a trend towards significant
difference (p=0.06) between groups for DT gait speed (backwards counting). The MCTT group
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38
increased by 4.1m/min yet the MC group decreased speed by 3.7m/min. This study provides a
methodological framework in how to develop a music-based training for those with dementia.
In a 12-week RCT (173), 76 community-dwelling participants (aged 60+) were
randomized into one of four training combinations: 1) MM (aerobic and resistance training), 2)
MC (MM + dual-task cognitive training) 3) stretching and 4) computer lessons control group. All
groups improved their 6MWT, processing speed and inhibition scores similarly, there were no
interaction effects. Those in the MC group demonstrated increased task-switching abilities
(p<0.01). The authors explain that the MM and MC groups’ exercise intensity may have been too
low and that each group had the similar amounts of social/intervention time, and these may be
reasons as to why all groups improved similarly over the 12-weeks.
Sixty-nine participants (65+), with MCI, were enrolled in a 24-week RCT intervention
(174) that included 4 groups: 1) aerobic, 2) cognitive 3) MC 4) life-as-usual control group. Of 11
outcome measures, the cog-only group improved in 2 (both cognitive measures), the aerobic-
only group improved in 2 (1 motor and 1 cognitive), and the MC group improved in 8 measures
(4 cognitive and 4 motor). Authors suggest that the combined training may have a significant
role in improving both types of function, then single training alone and that a longer intervention
may have led to even greater effect sizes. Those who have MCI have higher chances of it
progressing into dementia, maintaining cognitive and physical performance is of utmost
importance in this population in order to attenuate the functional declines associated with MCI,
and delay the onset of dementia.
Ten participants (65-85 yrs.) were enrolled in a pre-post study (175) to assess whether a
MC intervention (treadmill walking while performing a variety of dual tasks) may improve gait
and cognition in older fallers. After the 6 weeks, ST and DT gait speed (17.3% and 17.0%,
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39
respectively) and step length (8.5% and 8.9%, respectively) improved, 6MWT improved by
13.2% and executive control by 12.7%. Authors conclude that the progressive training may be
the reason behind the observed improvements. They also state that the treadmill-only training
may be the reason why significant, but not clinically meaningful, changes were seen in the
6MWT; it may be easier to walk on the treadmill compared to walking over ground.
Nevertheless, a combined motor-cognitive training program is feasible and effective in
improving gait, endurance and executive control in older adults with a high risk of falls.
A 12-week RCT (20) enrolled 36 community-dwelling adults (65-80 years) into a either a
MM (aerobic, strength, coordination and balance training) group or MC (MM + simultaneous
cognitive tasks) group. ST and DT gait performance significantly, but not clinically, improved
with large effect sizes in both groups, while cognitive performance (inhibition) increased only in
the physical-cognitive training group. This type of combined intervention may help older adults
maintain or improve their overall motor and cognitive function, allowing them to meet the
demands of daily life.
A six-month RCT with 100 participants (71.5 avg. age) with MCI (176) were randomized
into a supervised intervention of either HIIT resistance training (PRT), cognitive training (CT),
HIIT resistance training plus cognitive training (PRT+CT) or a control group. Participants were
assessed on cognitive outcomes: executive function, memory, attention, and global cognition.
Significant improvements in global cognition, executive function and verbal memory were found
only in the PRT group. In contrast the CT group only improved in memory. The PRT+CT group
performed significantly worse than PRT in executive function and global cognition. Since these
results are not in agreement with other studies that have seen additive benefits when physical and
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40
cognitive trainings are combined, the authors posit that perhaps the intervention was too
challenging, causing excessive stress in the PRT+CT group.
Mavros and colleagues (177) conducted a secondary analysis on the 6-month RCT
discussed above (176) to determine if strength changes mediate cognitive function. One hundred
participants (55+) with MCI were randomized into one of 3 groups: PRT (HIIT resistance
training), CT (Cognitive Training), PRT + CT, or control. They found that in the PRT group,
lower-body strength gains, but not aerobic changes, mediated their global cognitive
improvements, but not executive domain measures. These results provide evidence that PRT is
effective in improving cognitive function, and also that future HIIT resistance training
interventions should maximize strength gains in order to result in higher levels of cognitive
improvement.
Eighty participants (aged 65-75) diagnosed with MCI were enrolled in a 10-week MC
intervention (178). The MC group had combined balance training with cognitive training, while
the control group had only balance training. The combined training had larger improvements in
cognitive function (attention, memory, and language), postural control and balance than in the
balance-only training group, with small to moderate effect sizes. Combining both balance and
cognitive training may lessen the deterioration of cognitive abilities and the associated declines
in postural control and may be recommended as a therapeutic intervention for those with MCI.
A 24-week RCT enrolled 63 community-dwelling adults (55+), with self-reported
cognitive complaints or MCI, into a MM (aerobic and strength) or MC (aerobic and strength + a
cognitive-based stepping exercise) to examine the effects on executive control (179). Both
groups improved executive control reaction times. The authors conclude that the MC
intervention did not demonstrate added benefit over MM training alone in their effects on
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41
executive control. This could be because the measure they used to assess executive control was
an anti-saccade task, which is not a typically-used neuropsychological assessment for executive
control.
A large 12-month RCT of 555 community-dwelling adults with MCI (60+) (180),
examined the effects of 4 interventions on cognition. Participants were randomized into a MM
(aerobic, stretching and toning), cognitive activities (playing board games), MC (MM + Cog), or
a social control group. Significant time*group interactions revealed that the MC group,
compared to other groups, had improvements in ADAS-Cog, delayed recall and verbal fluency.
Also, those with milder stages of MCI showed greater improvements, leading to the thought that
there may be a critical time period as to when an intervention should be implemented. They
conclude that low adherence rates (73%) may be a reason for not observing improvements in
other cognitive functions.
Another 12-week study (181) randomized 138 participants (age 61-84) into an MM
(aerobic, strength training), MC (simultaneous aerobic + cognitive), or control group, to examine
the intervention’s effects on reaction time. The MM group had the largest improvements
(p<0.001) over MC and control in both simple and choice reaction and movement times. MC had
improved (p<0.01), compared to controls, in simple reaction time, simple movement and choice
movement times. Reaction times are important predictors of older adults’ complex task solving
abilities and fall risk.
A four-month RCT (182), examined how MM (aerobic, strength training), Cog-only
training, or MC (MM + Cog) interventions affected fluid cognition as assessed by the Leistungs-
Prüf-System 50+ Test. All interventions led to an improvement, with moderate effect sizes, of
fluid cognitive performance. The MC group yielded significantly better results cognitive speed.
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42
The authors concluded that combined training may not be more beneficial than single-task
training alone.
A 6-month RCT (183) investigated how aerobic, cognitive and combined MC
interventions may affect “real-world” cognitive performance in 96 community-dwelling adults
(55-75 years). Those in the cognitive-only training improved in prospective memory, compared
to the other two training and control groups. This is most likely due to the transfer of skills from
the cognitive training program, which included prospective memory tasks, to the actual
assessment of prospective memory.
In a 12-week RCT (184), 48 community-dwelling adults (avg. age 73.2 yrs.) were put
into a MC (aerobic, strength, stretching, and cognitive tasks during exercises) intervention or
control group. MC group had greater improvements in processing speed, logical memory and
executive functions, than the control group, as well as self-selected gait speed (5.3%, p=0.004).
Participants also underwent fMRI scans, the MC intervention led to decreased brain activation
associated with short-term memory; these findings suggest that combined exercise interventions
may improve brain efficiency along with in older adults leading to improved cognition.
A 4-month quasi-experimental study (185) aimed to identify the effects of a MC
intervention on ST and DT gait in 23 adults (age 65+) with Alzheimer’s disease. There were 2
groups: MC (simultaneous motor (aerobic, strength, balance, flexibility, and agility) and
cognitive task (word generation, whistling) and usual-care control group. The MC group
improved ST (14.5%) and DT (18.9%) gait speed, ST (8.1%) and DT (8.7%) stride length, and
ST (5.9%) and DT (9.7%) cadence compared to the controls.
Pereira and colleagues (150) examined the feasibility of a 10-week quasi-experimental
MM/MC exercise program with 34 (aged 65+) nursing home residents. Intervention participants
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43
increased their ST gait speed (19.1%), balance (25.8%), lower-body strength (40.7%), agility
(15.6%) and aerobic endurance (10.7%), compared to controls. They also improved their
planning ability (25– 32%) and selective attention (19–67%). These key findings provide
evidence that the MM/MC program was safe, feasible and able to turn around the usual loss of
cognitive and motor function in institutionalized older adults.
A 3-month RCT (186) study aimed to compare the impact of 1. MM (aerobic and
resistance training), 2. Computerized cognitive training (cognitive tasks and stretching) 3. MC
(combination of both) and 4. Stretching and computer lessons (Control Group) on self-selected
gait in 90 community-dwelling adults aged 60+. All combinations of training were performed
sequentially, and not simultaneously. Improvements in gait speed were found in all groups
except group 4 (stretching and computer lessons). Clinically meaningful gait speed changes
(>0.10m/s) were found in groups 1 and 3. Authors suggest that the improvements were induced
by the specific component of each training program being performed on its own and not
simultaneously.
A 16-week RCT (187) investigated the effect of a MC (gross motor movements and
complex information processing) training program on cognitive function of 90 community-
dwelling adults (81.5yrs avg. age). Compared to controls, the MC group improved significantly
in processing speed (p<0.05), visual-spatial ability (p=0.01) and concern about falling (p=0.04)
but not divided attention. Processing speed and visual-spatial skills are important for everyday
life and navigating challenging environments, declines in both of these skills has been linked to
falls in this population.
Shimada and colleagues (188) conducted a 40-week RCT in participants (65+) with MCI.
The MC intervention simultaneously combined physical (aerobic, strength and balance activities)
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44
with cognitive training (word games while stepping), which they termed “cognicize”. The MC
group’s logical memory scores improved by 21%, steps per day increased by 25% and minutes
of moderate-vigorous physical activity increased by 58% per day, while there were no changes in
the control group. Enhanced memory function, in particular with patients with MCI, may delay
progression to Alzheimer’s disease or other types of dementia.
An 8-week study (109) examined a MC intervention’s effects on ST and DT gait in 39
adults (55+) with early-stage dementia. The intervention included walking, resistance, balance
and flexibility training with cognitive tasks plus art therapy. There were no pre-to-post changes
in ST gait speed, however, participants did improve their DT (serial subtraction by 1’s) gait
speed both significantly and clinically (small MCID of 0.05m/s) by 12.2%. Their MMSE scores
also improved by 11.6%. Deterioration in both ST and DT gait speed is expected in this
population, so observed improvements in DT gait speed, along with maintained ST gait speeds,
is an important finding. Combined interventions such as this one may allow cognitively-impaired
older adults to better allocate their cognitive resources when completing a task with competing
cognitive requirements (e.g. walking and talking on the phone) in everyday life.
Wang and colleagues (189) conducted a 12-week intervention in 225 stroke survivors
(avg. age 65.9 yrs old) with vascular cognitive impairment. Participants were randomized into
one of 4 groups: MM (aerobic, endurance, strength and balance), cognitive-only, MC (MM +
cog-only), and control group (usual care and documentary viewing). The MC intervention
resulted in greater improvements in all 4 cognitive tasks (cognitive flexibility (7.1%), selective
attention (4.0%), working memory (13.6%), and mental rotation (17.3%)) compared to either
single-training intervention alone. These effects were sustained long-term, as assessed at a 6-
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45
month follow-up. The authors conclude that the combination of physical and cognitive training
may result in neural enhancement, leading to increased neuroplasticity and cognitive function.
A 4-week RCT (190) compared 4 home-based interventions on gait and balance
performance in 60 community-dwelling adults (aged 65+). The 4 groups were: 1. Motor training,
2. ST cognitive training, 3. Motor-cognitive training (MC) or 4. DT Cognitive-cognitive training.
Gait measures included ST narrow walking and DT narrow walking. MC training was more
effective than motor training, but not cognitive training, alone in increasing ST and DT narrow
walking speed (17.9% and 22.2%, respectively). Cognitive training group improved both ST and
DT narrow walking speed by 18.5% and 26.3%, respectively. This is one of the first studies to
implement a home-based MC training. Findings also suggest that all training programs should
incorporate a cognitive component as part of any intervention seeking to improve balance and
gait in this population.
In summary, the majority of studies investigating a combined physical and cognitive
training intervention (either sequentially or simultaneously) resulted in larger effects on
cognition and gait than those of physical or cognitive training alone. These findings seem
particularly robust in populations with MCI, dementia or Alzheimer’s disease. The lengths of
these interventions ranged from 4 weeks to 12 months, meeting anywhere from 1-3 times per
week. With such varied prescription parameters, it is difficult to assess what the optimal length,
frequency and intensity should be in order to observe large effects of a MC intervention. Also,
another issue facing researchers in this field is in deciding which type of cognitive training to add
to the physical training: one that is challenging enough to stimulate change, but not so difficult
that the participant gives up, loses motivation, or drops out of the study all together.

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Cognitively-demanding Physical Activity (CPA) Interventions
There are some activities that are inherently both physically and cognitively demanding.
These would include, as mentioned in the introduction, activities such as dance, tai chi, yoga, and
golf. While there are many reviews focused on MM and MC interventions that have included
CPA studies, no review has exclusively examined this type of intervention. The final section of
this review will present the current research that has investigated the effects of dance, tai chi,
yoga, and golf on gait and cognitive performance in older adults.

Dance
A 40-week RCT (136) enrolled 201 community-dwelling adults with MCI (avg. age 76.0)
into one of three groups: 1) dance, 2) playing musical instruments or a 3) health education
control group. The dance group improved in logical memory (p=0.01) compared to music and
control groups. Both the dance (p=0.03) and music (p=0.008) groups improved in global
cognition, while there were no changes in the control group. There were no differences between
groups for word recall, attention or executive control. Both dancing and playing musical
instruments include physical, mental and social components; these combined components may
be what was driving some of the cognitive improvements in these participants with MCI.
Dominguez and colleagues (191) conducted a 48-week quasi-experimental study
examining how a dance intervention affected cognitive performance in 207 adults with MCI
(60+). Those in the control group continued life as usual. Those in the dance intervention
improved ADAS-Cog score (p=0.03), global cognition (p=0.003) and language processing
p=0.04), controls had no change. The dance intervention incorporated cognitive and social
stimulation, physical fitness and integrated sensory motor skills; each week also progressively
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47
increased in difficulty which added to its complexity. The unique synthesis of various factors
resulted in improved cognition in a population where observable declines would be expected
over a 48-week period.
A 6-month RCT study (130) had 3 groups (71 healthy, community-dwelling adults aged
70+): treadmill training alone, and two cognitive–physical training variations: 1) dance and 2)
treadmill training with a simultaneous verbal working memory task. Both cognitive–physical
programs were more effective than the treadmill-training group alone, and improved
performance in measures of executive function (p=0.03), processing speed (p<0.001), and
episodic memory (p=0.002). They concluded that multicomponent, simultaneous cognitive-
physical training programs have the potential to improve cognitive function through activation of
certain brain networks which are associated with higher levels of cognitive function. The same
study, but published in a different paper, (192) examined the three interventions’ effects on gait
performance. There were no differences between training groups after the intervention, all
participants had improved gait performance. Treadmill-only intervention improved 6MWT
(6.3%), ST gait speed (13.2%) and DT gait speed (14.8%). Dance intervention improved 6MWT
(10.9%), ST gait speed (8.5%) and DT gait speed (9.6%). Memory + treadmill intervention
improved 6MWT (8.4%), ST gait speed (15.4%) and DT gait speed (14.7%). The simultaneous
cognitive-physical interventions did result in significant reductions of dual-task cost, which was
not found in the treadmill-only group, which may be a reflection of the increased cognitive
performance in the two groups.
A 12-week quasi-experimental study (193) investigated whether a tango intervention vs.
a health education intervention affected motor–cognitive function, mobility, and gait in 54
community-dwelling adults aged 59-95. Tango participants improved fast gait speed (9.1%), and
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48
backwards gait speed (13.5%), but not self-selected gait speed, compared to control group.
Tango participants did not improve, but did maintain, cognitive function over the 3-months.
Authors posit that this type of intervention may be an effective strategy for maintaining
independence and enabling aging in place in this older population.
A 6-month RCT study (108) investigated the effects of a dancing program on motor-
cognitive dual-task performance. Thirty-five community-dwelling adults (65+) were assigned to
a dance group or MM (endurance, strength, and flexibility) group. All participants increased
dual-task (serial subtraction by 3s) gait speed, regardless of training. However, the dance group
did take significantly less time to recite the subtractions than the MM group, which the authors
are suggesting is an improvement in cognitive performance. Hence, they posit that dancing, with
its memorization of choreography, could be a potentially powerful intervention to improve dual-
task performance among older individuals.
Another 10-month RCT (142) investigated the effects of International Ballroom Dancing
on cognitive function in 129 adults (55-75) diagnosed with MCI. Using independent sample t-
tests, the dance group maintained cognitive performance, while the life-as-usual control group
significantly declined on all cognitive measures. It was suggested that dance may be used as an
adjunct treatment to pharmaceutical treatments in this population. Furthermore, they suggest that
future studies should investigate the effects of dance therapy compared with
conventional/pharmaceutical therapies.
Merom and colleagues (144) conducted an 8-month RCT with 115 community-dwelling
adults (avg. age 69.5 yrs.) to determine whether a dance intervention could benefit executive
function compared to a walking intervention. Cognitive measures included processing speed,
inhibition, episodic memory, working memory and visual-spatial memory. The dance group
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49
improved in spatial memory (p=0.02), compared to the control group (p=0.20). This is not
unexpected given how important spatial memory is for performing dance moves. Authors
suggest that since all participants’ baseline activity levels were high, this might have led to
ceiling effects and no changes either between or within groups.

Yoga
Eighty-one adults diagnosed with MCI (55+) were randomly assigned to either a
Kundalini yoga intervention group or a memory training group for 12 weeks (138). Yoga had
similar effects as memory training on logical (p<0.0001) and visual (p<0.01) memory, and
stronger effects on executive function (p<0.01) than memory training. The memory-training
group improved in episodic memory (word recall, p<0.01), whereas there were no changes in the
yoga training group. Authors concluded that the “brain-fitness” effects of this yoga intervention
may be explained by the multifaceted training of Kundalini yoga (physical poses, visualizations,
and kirtan kriya meditation). This same type of Kundalini yoga intervention resulted in increased
language network functional connectivity (via fMRI) and improved cognitive performance in a
previous study conducted by the same authors.
Another RCT (90) examined the effects of an 8-week Hatha yoga intervention on
executive function measures in 118 community-dwelling adults aged 55-79. Participants were
randomized into either the yoga training group or a stretching/strengthening control group. The
yoga group demonstrated improved performance in task switching (p<0.05) and working
memory capacity (p=0.01), compared to the control group. However, the partial η2 effect sizes in
this study ranged from small to moderate (.02 to .08), this may be due to the participants having
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50
had no cognitive impairments and greater effects may be found in populations with MCI or
dementia.
A 10-week RCT (140) investigated the effects of a Iyengar yoga intervention on physical
performance with 46 healthy, sedentary adults (age 60-89). Participants were randomized into
either the yoga training group or a health education control group. Intervention participants
improved their self-selected gait speed, with a small effect size (0.17). The health education
group was exposed to topics that may have directly changed their behavior and this could be a
factor in why there were improvements in some physical performance measures also observed in
the health education participants.

Tai Chi
In a 10-week RCT (139), 48 adults diagnosed with MCI (age 65+) were randomized into
either a Tai Chi + cognition group or a cognition-group only. After 10 weeks, there were no
differences between groups. Both groups improved in gait, processing speed and selective
attention. Tai Chi + cognition training did not result in any added benefits over cognitive training
alone. Authors posit that this could be due to the length of the intervention being too short, and
that both groups, despite having MCI diagnoses, were physically high-functioning older adults.
Larger effect sizes may have been seen in a frail population or with an intervention that was
longer in duration.
A 12-week RCT (135) included 110 (avg. age 80.0yrs old) adults diagnosed with
dementia into a Tai Chi group, cognitive-only (mahjong game) group or a social control group.
While the control group declined in all cognitive measures (global cognition, working memory,
word recall, and verbal fluency), both the Tai Chi and cognitive-only groups maintained their
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cognitive functioning, which would not be the typical downward progression expected for this
population. Both Tai Chi and mahjong are cognitively complex activities, Tai Chi requires
memorizing complex movement sequences and these complexities may have added benefits
when compared to less cognitively complex exercises. This study points to the feasibility of
implementing a CPA intervention using Tai Chi in an institutionalized setting that was safe and
effective for residents with dementia.
A 14-week quasi-experimental study (145) aimed to evaluate whether Tai Chi could
improve global cognition and gait in 46 persons (aged 65+) diagnosed with MCI. The Tai Chi
group improved in global cognition (12.8%), fast gait speed (13.3%) and TUG (14.9%), control
group did not change. Tai Chi is multifactorial, combining physical and cognitive demands
(selective attention, working memory, and executive function) that are unique to this ancient
martial art, yet still feasible and effective in an older population with cognitive impairments.
A 12-week quasi-experimental study (143) investigated the effects of Tai Chi training on
physical performance including dual-task gait in 57 adults (avg. age 87.0 yrs.) living in
supportive housing facilities. Self-selected (p<0.001) and dual-task gait speed (p<0.001)
improved compared to controls, but not TUG performance. Authors conclude that, in very old
adults living in supportive housing facilities, Tai Chi training is safe and effective in improving
gait performance.
Siu and colleagues conducted a large, 16-week quasi-experimental study (95) with 160
adults (age 60+) diagnosed with MCI. Participants were assigned to either a Tai Chi group or
life-as-usual group. Those in the Tai Chi group scored better on global cognition (5.4%,
p<0.001), compared to controls. Authors explain that the added component of meditation in Tai
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Chi could also add to its effectiveness in preserving cognitive function, through increased
relaxation and stress reduction.
A 6-month RCT (96) investigated the effect of Tai Chi on physical and cognitive function
in 150 community-dwelling older adults. The Tai Chi group improved their self-selected and fast
gait speed (4.4% and 3.5%, respectively), while the control group decreased their self-selected
and fast gait speed (-8.0% and -10.1%, respectively). Global cognition and frontal assessment
battery scores also increased in the Tai Chi group, while there were no changes in the control
group.
A 6-month RCT (97) Examined the effects of Tai Chi on cognitive function and blood
plasma biomarkers in 66 adults (avg. age 67.9yrs.) diagnosed with MCI. Participants were
assigned to either the Tai Chi group or a health education group. Tai Chi participants improved
in logical memory (54.4%) and mental switching (24.4%) compared to controls. Tai Chi group
also had higher levels of peripheral BDNF (p=0.04) after the intervention, levels of TNF alpha
and IL-10 (inflammatory biomarkers) were not different compared to controls. BDNF is
implicated in neurogenesis by mediating the long-term benefits of exercise on brain function,
which may have led to the improved cognitive performance in the Tai Chi group.
A 12-week study RCT (146) examined two types of tradition martial arts: Tai Chi and
Baduanjin and how they affected functional connectivity and memory function in 62 community-
dwelling adults (50-70). Participants were assigned to one of three groups: Tai Chi, Baduanjin,
or a health eduction control group. After 12 weeks, memory function improved in both exercise
groups (Tai Chi: 16.8% and Baduanjin: 26.0%), compared to the controls. The Tai Chi group
also had enhanced functional connectivity between the bilateral hippocampi and the right and left
medial Prefrontal Cortex (PFC), compared to the control group. Both Tai Chi and Baduanjin are
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mind-body exercises that emphasize both physical and mental training, sustained attention and
multi-tasking; the connectivity between the hippocampus and the PFC has been shown to be
enhanced during successful encoding of new information. All of these factors may be the
responsible for the observed improvements in memory function.
Zhuang and colleagues (53) aimed to evaluate the effectiveness of a 12-week exercise
intervention that included Tai Chi, balance, and strength training. Fifty-six community-dwelling
adults (60-80 years) were randomized into either the exercise group or a life-as-usual control
group. Self-selected gait speed, step length and cadence increased (17.3%, 11.1%, and 6.6%,
respectively) after the 12-week intervention in the exercise group with large effect sizes, there
were no changes in control group. Lower-extremity isokinetic strength measures, particularly at
the ankle, also increased which may have resulted in the improved gait performance. The authors
concluded that future studies need to compare the effect of this combined intervention with Tai
Chi training alone or strength training only, in order to differentiate which components of the
intervention have the most potential to impact gait performance.

Golf
Researchers in the same lab conducted two studies investigating the effects of golf
training on cognition in patients with stroke. In the first 10-week quasi-experimental study (25),
24 patients (age-23-72) with stroke were assigned to either a modified golf-training group or a
social control group. Golf sessions were held on a putting green inside a laboratory. During the
20 sessions, golf participants were asked various cognitively-challenging questions while they
putted. Those in the intervention group improved in a visual imagery task (mental rotation) with
a large effect size (d=1.49), but not attention or visual-spatial memory. Improvements in the
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mental rotation task may be due to the fact that the golf exercises included visual imagination
tasks, which are important skills for patients recovering from stroke to have for everyday
activities (e.g. reaching for a glass of water). A follow-up study by the same research group (26)
did not use a modified golf intervention, instead, participants were on an actual golf course for
10 weeks. Twenty-one participants were either assigned to the golf training group or a social
control group. Similar results to the earlier study were found: golfers improved their visual
imagery task (mental rotation), but not balance or visual-spatial memory. None of the
participants were in the acute stage of stroke recovery; more robust, beneficial results may have
been observed if those in the golf intervention had been closer to the time of stroke occurrence.
A 24-week RCT study (24) examined the effects of golf training on gait and cognition in
healthy, community dwelling older adults (65+). Improvements were observed for immediate,
delayed and composite logical memory performance (9.1%, 11.6%, and 10.3%, respectively), but
there were no improvements in self-selected gait speed, episodic memory (word recall),
attention, executive function or processing speed scores in the golfers, compared to controls. The
authors give the explanation that the golfing group may have had an insufficient amount of
physical activity during the 24 weeks, as they were on the golf course for only 10 sessions of the
24-week duration. In contrast, the GIVE study was only 12-weeks, but had 18 sessions of play
on the golf course. GIVE participants improved in fast ST and DT gait performance, 6MWT,
delayed episodic memory and fluid cognition, whereas no changes were observed in controls on
these measures.
A pre-post study (27) enrolled 11 patients with stroke into a 6-week golf training
intervention. All sessions took place on a 3-hole short course community golf course. Gait and
cognition were not measured, but other physical health outcomes were coordination, strength,
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agility (TUG), and balance. Post-intervention improvements were observed in coordination
(p=0.004), balance (p=0.002) and strength (p=0.002), but not agility (TUG) or sit-to-stand
measures. Given that there was no control group to compare results with, caution is
recommended when interpreting results from this study.
Only one group of researchers has examined neural changes as a result of participating in
a golf intervention. Bezzola and colleagues measured both structural (23) and functional (92)
brain changes in 22 healthy, middle-aged (40-60) participants that had completed a 40-hr golf
training program or were assigned to a control group. Golfers increased gray matter volumes,
while gray matter volumes were maintained or reduced in controls. Increases were observed in
areas associated with the dorsal stream and regions critical to motor learning (left primary motor
and primary sensory cortices, left premotor cortex, bilateral inferior parietal lobule, and right
parietal-occipital junction). Functional connectivity (FC), during mental rehearsal of the golf
swing, in the right dorsal premotor cortex was reduced post-training. This reduction was
hypothesized by the authors, as one becomes more skilled at a novel task, there is an increase in
neuronal efficiency and less brain activation is needed.
Ten professional female golfers and 10 age-matched controls participated in a cross-
sectional study investigating functional brain connectivity using resting-state fMRI. Results
provide evidence (72) that professional golfers have enhanced FC between cerebellum and
frontal, temporal, and parietal lobes that are associated with working memory tasks, compared to
non-golfers. Expert golfers’ long-term practice results in highly developed neural networks that
are activated during motor planning. This study had a small sample size and consisted of only
females; despite these limitations, this study is one of the only studies using neuroimaging to
explain neural mechanisms underlying golf play. These enhanced neural mechanisms (both
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structural and functional) may be responsible for improvements observed in physical and
cognitive performance, not only in the golf interventions, but also the other cognitively-
demanding physical activities discussed in this section.
In summary, physical activities that are inherently both physically and cognitively
demanding seem to be as effective as MC interventions, especially in participants with cognitive
impairment. One advantage of CPA interventions is that they may be more efficient, as it takes
more time to incorporate 2 separate paradigms (treadmill walking, then cognitive games), than to
take a dance or tai chi class or play a few holes on the golf course a few times a week. Future
studies might incorporate these CPA’s into an intervention, as they are utilized by many people
into their 70s, 80s, and 90s to stay healthy, mobile, and active.
This review has demonstrated that overall, MM, MC and CPA interventions have
beneficial effects on both gait and cognition in older adults with and without physical or
cognitive impairments. It is difficult to conclude which cognitive assessments are the most useful
to incorporate, as well as, what prescription for duration, frequency and intensity is most
advantageous. Only some studies assessed both gait and cognitive function, since there is a large
association between these two functions, it would be suitable for future studies to measure both.
Future studies would also do well to include active and non-active control groups, measure
plasma biomarkers (e.g. BDNF), as well as incorporate more neuroimaging assessments, in order
to provide more robust evidence of the underlying neural mechanisms by which these physical
and cognitive functions are improving.

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CHAPTER IV
CHANGES IN OLDER VETERAN’S WALKING PERFORMANCE AND GAIT
MECHANICS FOLLOWING A 12-WEEK GOLF TRAINING PROGRAM: THE GOLF
INTERVENTION FOR VETERANS EXERCISE (GIVE) STUDY

Abstract

Background: Age-related declines in walking speed are associated with poor health outcomes,
disability, hospitalization, increased fall risk, cognitive decline and mortality.
Research Question: Can a 12-week golf training program improve gait performance and alter hip
joint kinetics in older military Veterans?
Methods: The Golf Intervention for Veterans Exercise (GIVE) study was a Phase I, 12-week golf
training intervention study. Twelve male military Veterans (average 70.4 ± 4.8yrs) were enrolled
in and completed the intervention. Pre- to post-intervention changes in gait, including six-minute
walk test, fast gait speed, stride length, cadence and sagittal plane hip joint kinetics were
measured.
Results: Participants completed an average of 21.8/24 sessions (91% adherence rate). There were
no program-related adverse events. Golf training significantly increased average six-minute walk
test (9.3%), fast gait speed (6.7%), stride length (4%), peak hip extensor moment (16.5%) and
peak hip extensor power generation (46.5%).
Significance: The increased hip joint kinetics that accompanied the changes in six-minute walk
test and fast gait speed can be attributed to the physical demands of the 12-week golf program,
which included walking the golf course, high-powered swings and bending /squatting activities.

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Introduction
Slowing gait speed and altered gait kinetics are inevitable as one ages. The relation
between aging and gait speed is so salient, that gait speed has been called the "sixth vital sign"
(2). In older adults, decreased walking speed is associated with poorer health outcomes,
disability, hospitalization, increased fall risk, cognitive decline and mortality (2,3,5). Age-related
declines are also observed in one’s functional ability to walk longer distances. Typical
biomechanical markers of slowing gait speed and gait dysfunction in older adults include shorter
stride length and increased cadence (52,64,194). These age-related changes in gait have been
primarily attributed to the loss of plantarflexor strength and power generating capacity
(59,62,157).
There is increasing evidence acknowledging the benefits of multimodal interventions for
improving gait and overall fitness (28,149). Golf is a multimodal intervention that includes
components of aerobic fitness, strength, balance, coordination, strategic cognitive processing and
social engagement; however, there are only a few studies which have examined golf as a
therapeutic intervention (24–26). We believe the combination of physical demands during a
round of golf such as walking on uneven terrain and up and down steep hills, bending/squatting
to pick up a golf ball, pulling/pushing a cart, high-powered golf swings and navigating obstacles
may make golf a unique activity for increasing, or maintaining, walking dynamics as one ages.
The golf swing and lunges/squats performed to engage with the golf ball are movements that
require large hip muscle demands. Previous studies have demonstrated that large hip extensor
and flexor moments at the hip joint are produced during the golf swing, resulting in large hip
joint power generation (66,67). To increase gait speed and stride length, older adults have been
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59
reported to increase power generation of the hip extensors (52,60,65). In contrast, younger adults
rely on increased power generation at the ankle to improve gait speed (52,59,62,64,65,157).
The purpose of this Phase I, feasibility study was to examine the effects of a 12-week
golf training program (GTP) on gait performance and sagittal plane hip joint kinetics in older
military Veterans. Given that golf includes considerable walking and involves two major
components (swings and lunges/squats) which have high hip muscle demands, and that older
adults tend to utilize their hip joint to increase gait performance, we hypothesized that the GTP
would increase six-minute walk test distance (6MWT), gait speed, stride length, and sagittal
plane peak hip moments and extensor power generation.

Methods
Participants
Twelve healthy, community-dwelling older military Veteran males participated in and
completed the 12-week training program (age 70.4 ±4.8yrs, height 1.77 ±0.06m, mass 100.9
±24.8kg, BMI 32.3 ±8.1). All participants were between the ages of 60-80 years old, were
current non-golfers (8 had never played golf, 2 had played <2 times in the past 5 years, and 2
played less than 5x in the past 20 years), were able to walk independently and were free of
physical or cognitive disabilities. Exclusion criteria included any neurological, musculoskeletal,
autoimmune or other medical condition that may affect gait or limit physical activity (Table 4.1).
Individuals were also excluded if they did not receive medical clearance and approval
from their primary care physician to join the GTP. Participants were recruited through physician
referrals, word-of-mouth, flyers, visits to community centers and classes (both on and off
Veterans Administration (VA) campuses) (Fig. 4.1). All participants provided written informed
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60
consent prior to testing and were enrolled in the Golf Intervention for Veterans Exercise (GIVE)
study. This study was approved by the Institutional Review Board (IRB) of the University of
Southern California and the IRB and the Associate Chief of Staff for Research and Development
at the Veterans Affairs West Los Angeles Medical Center (WLAVA).
Golf Training Program Intervention
Participants began the 12-week GTP within 2 weeks of baseline testing. The
comprehensive program consisted of two, 90-minute sessions per week with a Professional Golf
Association (PGA) instructor who had 40 years of experience teaching golf and took place at the
Heroes Golf Course, located at the WLAVA. In order to avoid injury and prepare the participants
for the rigors of golf, each session began with a series of warm-up and complimentary
conditioning exercises, followed by progressive golf training (for a detailed weekly training
outline please refer to (195)). The exercises included body-weight squats, heel raises, standing
leg raises, quadruped hip extensions, bridges and upper-body exercises using a resistance band.
Exercise time was 45 minutes for the first 3 weeks, then as golf play increased, it was gradually
reduced to a 10-minute dynamic warm up during weeks 7-12 (for complete complimentary
exercise protocol please refer to (195)). During the first 3 weeks, participants started with swing
training (using different clubs for tee-off, chipping, pitching and putting). During week 4,
participants started on the course playing 2 holes and progressively increased the number of
holes played, until eventually they completed the entire 9-hole course during week 12. As
detailed previously (195), this intervention was designed to safely and effectively teach non-
golfers to become independent golfers by the end of the 12-week intervention. Participants were
requested to maintain physical activity levels during the 12-weeks, and not alter their other
physical activity.
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Activity Levels
Participants completed physical activity logs at baseline and follow-up (195,196). Logs
were reviewed at the end of the 12 weeks to ensure there were no changes in activity levels from
baseline to follow-up testing. This was achieved by totaling the minutes of weekly structured
exercise time (e.g. walking, cycling, gym, and racquetball) at baseline and at follow-up.
Walking Performance and Biomechanics
Laboratory Gait: Before and after the GTP, participants underwent gait analyses at the
USC Jacquelin Perry Musculoskeletal Biomechanics Research Laboratory. Participants
performed the gait assessments using a standard lower-extremity marker set (197) with a 10-
camera Qualisys Oqus 5 motion analysis system (Qualisys Inc, Gotëborg, SE). Segmental
kinematics were collected at 60 Hz and ground reaction forces (GRF) were collected at 1500 Hz
using 3 AMTI (OR-6-1000) force platforms (Newton, MA). Both the GRF and segment
coordinate data were filtered with a 4
th
order low-pass Butterworth filter with a 6 Hz cut off.
Qualisys Track Manager Software (Qualisys Inc, Gotëborg, SE) was used to synchronize the
segmental and GRF data. All gait measures were calculated and processed using Visual3D
software (C-motion, Inc. Rockville, MD).
Participants performed 5-10 self-selected fast speed walking trials, along a 10m pathway,
with embedded force platforms. The pathway included 1.5 m acceleration (walk-in) and 0.5 m
deceleration (walk-out) distances; thus, gait trials were collected over the middle 6 m distance.
Participants were instructed to “Please walk as fast and as safe as possible.”
Ecological Gait: After the laboratory gait measures were recorded, the reflective markers
were removed and the participants then performed 6MWT (198). The 6MWT was completed on
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an even, concrete walking path without obstacles. Participants were instructed to “walk as fast
and safe as possible, covering as much distance as possible in the 6-minute time limit.”
Data and Statistical Analyses
The first 3 successful trials with a similar gait speed (±5%) were used for analysis. Gait
speed, peak sagittal plane joint moments and joint power at the hip over the entire gait cycle
were calculated and averaged from these 3 trials. Peak internal net joint moment and power were
normalized to body mass.
Data were screened for normality of distribution and outliers using the Shapiro-Wilk test.
All variables, including activity levels, were normally distributed and were analyzed using paired
t-tests comparing pre-post values. Pearson’s product-moment correlation coefficients (r) were
calculated to determine the association between changes in gait speed and changes in stride
length. All statistical analyses were performed with PASW Statistics (Version 18, IBM Corp.,
Chicago, IL). Significance level was set a priory at α=0.05. Means, standard deviations (SD) and
effect sizes (ES; Cohen’s d) are presented. Cohen’s d effect sizes are categorized as small d =
≥0.2; medium d = ≥0.5; large d = ≥0.8.

Results
Program Adherence and Adverse Events:
On average, participants completed 21.8/24 sessions. There were no program-related
adverse events and all twelve enrolled participants completed the program. Of these twelve, ten
were able to complete the follow-up testing and have their data analyzed. One participant was
unable to complete follow-up testing because of elevated blood pressure on the day of testing
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and one participant was excluded from analysis, following post-testing, due to a knee injury that
occurred outside of the training program.
Activity Levels
Participants did not alter physical activity, aside from the golf intervention, during the 12-
weeks; average reported weekly minutes of physical activity at baseline were 150 ±104 min, and
at follow-up were 157.1± 9 min (p=0.71).
Walking Performance and stride characteristics
6MWT, laboratory fast gait speed (FGS) and stride characteristics are presented in Table
4.2. Average 6MWT distance increased by 50.4 m (9.3%) with a large effect size (p=0.03; ES
0.81). Average FGS increased by 0.13 m/s (6.7%) with a large effect size (p=0.004; ES 0.82).
There was an increase of 0.07 m (4.0%) in average stride length with a medium effect size
(p=0.05; ES 0.73). There was no change in cadence (p=0.30; ES 0.35). Changes in stride length
correlated with changes in FGS (r
2
= 0.69, p= 0.03).
Hip Joint Kinetics
Table 4.3 summarizes the pre-post sagittal plane peak net joint extensor moments and
peak power generation at the hip joint. There was a significant increase of 0.2 Nm/kg (16.5%) in
the average peak net hip extensor moment with a large effect size (p=0.02; ES 0.89), following
the intervention. Peak extensor power generation at the hip increased by 1.1 W/kg (46.5%) with
a large effect size (p=0.04; ES 0.80) (Figure 4.2).

Discussion

Golf is a unique, multifaceted intervention, combining aerobic, strength, balance,
coordination, and cognitive components into one activity. This intervention was feasible, safe,
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64
effective and adherent. There were no golf-related adverse events during the 12 weeks and there
was a high adherence rate (91%). Participants did not change their typical weekly physical
activity behaviors, aside from the golf intervention; therefore, the improvements observed can be
attributed to their participation in the golf intervention. Golf is typically thought of as a “leisure
time” activity (195), not therapeutic exercise; however, this study demonstrated that participating
in a 12-week GTP improved gait parameters including 6MWT, FGS, stride length, and peak hip
sagittal plane net joint extensor moment and power.
The current study is one of few to examine golf from a health and wellness perspective
(24–27). Shimada and colleagues (24) investigated the effects of a 24-week golf intervention
(1x/week, 90-120 min/day) on health, including gait and cognition, in 106 older participants (65+
years). Although these authors reported improvements in immediate and delayed logical
memory, they found no changes in self-selected habitual gait speed, which was their only
reported gait measure. It should be noted that participants in the Shimada et al. study only
attended an average of 10/24 sessions playing on the golf course. In contrast, the participants in
the current study spent 18/24 sessions playing on the golf course, progressively increasing the
amount of walking, swinging and bending over to pick up their golf ball over the course of the
12 weeks (195).
Our participants increased their 6MWT distance by 50.4 m after completion of the
intervention. This improvement exceeds the established clinically significant difference for the
6MWT, which signifies an improvement in physical function, decreased risk of disability, and
improved health status and quality of life (198). The 6MWT assesses aerobic endurance and
functional exercise capacity (198,199), which is important for day-to-day activities such as
walking through neighborhoods, shopping malls, and grocery stores. Golf can be considered a
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65
moderate- to high-intensity aerobic activity in older males (21). The increases observed during
the 6MWT suggests participants’ aerobic endurance, and functional ability to walk, improved
over the 12-week intervention period. Evaluating both the 6MWT, as an ecological gait measure,
with FGS provides an overall global assessment of participants’ walking ability.
Average FGS increased by 0.13 m/s following the intervention period. These results
support previous reports of various types of exercise interventions improving FGS (149). A
recent meta-analysis (149) reported the effects of three types of exercise programs on gait speed
in older adults: resistance training, coordination training and multimodal training. All three
exercise modalities resulted in increased gait speed: by 0.11 m/s, 0.09 m/s and 0.09 m/s,
respectively. Another meta-analysis by Liu et.al., comparing the effects of resistance exercise
and multimodal exercise on physical function of older adults, found that there was no significant
effect of resistance exercise on gait speed; whereas, multimodal exercise was effective in
improving maximal and habitual gait speed (with pooled effect sizes of 0.31 and 0.50,
respectively) (200). Liu and colleagues concluded that resistance exercise may be more effective
in improving muscle strength and static standing balance, while multimodal exercises are more
effective in improving dynamic standing balance and gait speed.
Maximal gait speed provides insight regarding the functional ability of older adults when
maneuvering through their environment quickly, for example, while catching a bus, crossing the
street or avoiding unexpected vehicles (2,149). The improvement of our participants’ average
FGS of 0.13 m/s is considered clinically important; an increase in gait speed of 0.1 m/s is an
established minimally clinically-important difference (198) and is associated with increased
longevity, improved health status, increased physical function, decreased disability and hospital
utilization (3,5,198).
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Gait speed is a product of stride length and cadence (steps/minute). When compared to
young adults, older adults walk with a shortened stride length and increased cadence (64). Our
study participants’ stride length significantly increased by 4.0%, while there was no change in
cadence. As gait speed demands increase, older adults tend to maintain cadence and instead
change stride length (52,64). Our findings support previous studies that utilized yoga and
resistance training interventions. These studies found that, along with gait speed, stride length
significantly increased, not cadence (201,202). Similarly, power training interventions conducted
by both Beijerbergen et.al. (203) and Uematsu et.al. (54) resulted in significantly increased FGS
compared to controls, but neither stride length nor cadence had a significant increase along with
FGS. Uematsu and colleagues concluded that, although stride length increases were not
statistically significant, because FGS changes were highly correlated with stride length changes
(r
2
=0.89) in their training group and not their control group, increases in gait speed were driven
by stride length changes and not cadence. The current study participants’ increases in FGS and
stride length are closely related (r
2
= 0.69, p= 0.03); thus, it appears that changes in FGS were
driven by the increases in stride length.
In addition to the significant changes in 6MWT, FGS and stride length, we found
increases in peak hip extensor moment and peak power generation. Understanding the
biomechanical changes that accompany the changes in FGS may provide a mechanistic window
into how the golf program influences walking performance. Two important components of the
golf game that affect hip joint musculature and force production are 1) the golf swing and 2) the
lunges/squats used to tee-up, mark the golf ball or pick up the golf ball. The golf swing produces
large hip extensor and flexor moments in the sagittal plane, as well as power generation at the
hip joint (66,67). There is evidence that performing squats and swinging a golf club have similar
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67
hip joint loading demands (66,67). Our participants spent an average of 90-180 min/week
swinging a golf club and squatting and/or lunging to pick up their golf balls. These combined
activities, unique to the game of golf, may increase strength and force production about the hip
joint; resulting in an increase of power generation to the hip, and an increase in stride length,
walking speed and distance (65,157).
There are limitations related to this study, and these should be considered when
interpreting our results. First, we had a small sample size of community-dwelling older male
military Veterans, so caution should be used when extrapolating to older females or non-
Veterans. Second, conditioning exercises were performed at the beginning of the intervention for
the safety of the participants, and due to the design of this intervention program, it is not possible
to separate the effects of the exercises from the effects of golf training. Nevertheless, the
majority of time during the 12 weeks was spent in golf training (75%) and not performing
conditioning exercises (25%). Third, there was no control group in this Phase I pre-post study,
leading to a possible conclusion that the improved gait measures may be due to an unmeasured,
confounding variable. However, we would argue that this is unlikely in an older population, in
that gait ability is expected to decline, or be maintained at best, and not improve over time as was
demonstrated here.
In conclusion, this study demonstrated that the 12-week GTP was safe, adherent and
effective in increasing older military Veterans’ 6MWT distance and FGS via increased stride
length and mechanical output at the hip. Future studies may want to examine other populations
(e.g. those with osteoarthritis, stroke, or mild cognitive impairment). Future Phase II, and
eventually Phase III randomized trials, studies will be needed to determine if these findings can
be extrapolated to other aging populations, and if these improvements persist over time.
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Figure 4.1 Golf Intervention for Veterans Exercise (GIVE) Study Recruitment.

Figure 4.2 Sagittal plane net hip joint power ensemble-average curves during the full gait cycle
(n=10). Abs: absorption. Gen: generation. *significant pre-post difference (p<0.05). Mean ± SD.
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Table 4.1 Participant Inclusion and Exclusion Criteria for GIVE Study.
Inclusion Criteria Exclusion Criteria
¨ 60 – 80 years of age
¨ Military Veteran
¨ Had not golfed >1 time in past month and
had not golfed >3 times in past 6 months
¨ Could stand and walk independently
without assistance
¨ English speaking
¨ Had a primary care physician
¨ Dementia or Alzheimer’s disease
¨ Symptomatic cardiovascular disease,
active angina, uncontrolled hypertension
(>160 mm Hg/>90 mm Hg)
¨ Unstable asthma or exacerbated chronic
obstructive pulmonary disease
¨ Rheumatoid arthritis
¨ Unstable joints
¨ Orthopedic operation within past 6
months
¨ Movement disorders such as Parkinson’s
disease or other neurological disorders
¨ Stroke, hemiparesis, or paraparesis
¨ Peripheral neuropathy
¨ Severe vision or hearing problems
¨ Metastatic cancer
¨ Vestibular, visual, musculoskeletal,
orthopedic, and/or neurological disorders
known to impair balance

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Table 4.2 GIVE Participant Gait Changes from Baseline to Follow-up.
Table 4.2 6MWT, fast gait speed, stride length and cadence. Means, SD, ES and p-values.
Variable n=10

Gait Characteristics Pre Post
p-value
pre-post
Cohen's d ES
pre-post
6MWT (m) 539.9±99.4 590.3±83.8 0.030 0.81
Fast Gait Speed (m/s) 1.97±0.38 2.10±0.34 0.004 0.82
Fast Gait Stride Length (m) 1.73±0.20 1.80±0.20 0.046 0.73
Fast Gait Cadence (steps/min) 137±17.0 139±14.0 0.300 0.35
Significance level was set at <0.05 and is noted in bold. SD: Standard Deviation. ES: Effect size.

Table 4.3 Fast Gait Hip Sagittal Plane Peak Net Joint Moments and Power from Baseline to
Follow-up.

Table 4.3. Fast gait hip sagittal plane peak extensor net joint moments and peak power generation.
Means, SD, ES and p-values.
Variable n=10

Pre Post p-value pre-post
Cohen's d ES
pre-post
Peak Net Hip Joint Moment (Nm/kg)

Hip Extensor 1.4 ± 0.4 1.6 ± 0.5 0.02 0.89
Peak Power (W/kg)

Hip Generation 2.5 ± 0.8 3.6 ± 1.5 0.02 0.87
Significance level was set at <0.05 and is noted in bold.
SD: Standard Deviation. ES: Effect size.

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CHAPTER V
IMPROVEMENTS IN DUAL-TASK PERFORMANCE AND COGNITIVE FUNCTION
FOLLOWING 12 WEEKS OF TRAINING IN A COGNITIVELY-DEMANDING
PHYSICAL ACTIVITY—GOLF

Abstract
Golf is an inherently complex recreational activity that requires simultaneous physical
and cognitive demands. The purpose of this study was to investigate the effects of a 12-week
golf training intervention on dual-task (DT) gait performance and cognition in older military
Veterans. Using a quasi-experimental model, 25 military Veterans (60-80 yrs) were recruited, 12
were enrolled, and 10 completed the intervention (INT) and follow-up testing. A control group
(CON; n=10) was matched for age, education and physical activity levels. Single-task (ST) and
DT gait (subtraction by 3’s) and cognitive testing (California Verbal Learning Test, National
Institute for Health Toolbox-Cognition Battery) were measured at the start and end of the study.
A two-factor mixed-model ANOVA was used to test for training effects; post-hoc paired t-tests
were used to analyze significant interactions. Intervention adherence rate was 91%; there were
no golf-related adverse events. Post-hoc analyses revealed increases with large effect sizes in
average DT gait speed (9.9%, p=0.001) and stride length (4.3% p=0.003) for INT but no changes
in CON (p>0.05). Improvements were also found for long-delay episodic memory (45.8%,
p<0.001) and fluid cognition (15.3%, p=0.01), with large effect sizes for INT; however, CON
did not change (p>0.05). Neither group demonstrated change in DT cost. Participation in a 12-
week golf training program was feasible, safe, and improved DT gait and cognitive performance
in older military Veterans. Future studies examining this complex activity are needed to more
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fully understand how to employ recreational opportunities to improve both physical and
cognitive health in this population.

Three key words: dual-task gait, golf, cognition

Introduction
Maintaining physical capacity and preserving cognitive faculties are essential for older
adults to perform activities of daily living, remain independent, and stay active in their
community. For example, decreased gait speed and cognitive decline are associated with poorer
health outcomes, including increased fall risk, hospitalization, institutionalization, dementia, and
mortality (3). With the aging of baby-boomers comes the inevitable rise in cases of dementia and
Alzheimer’s’ Disease. It is estimated that by 2020, 423,000 older military Veterans will develop
dementia due to their high prevalence of risk factors for dementia such as hypertension,
traumatic brain injury, post-traumatic stress disorder and type-2 diabetes (204), and few meet the
recommended exercise guidelines (205).
Recent reviews have established, in older adults, that exercise is capable of improving
cognitive function, in addition to physical health (18,129). Moreover, studies in this population
suggest that multimodal and multicomponent interventions, which incorporate several exercise
elements (e.g., strength, endurance, balance, etc.,) and include concurrent cognitive challenges
(e.g., walking on the treadmill while performing arithmetic problems) have additive performance
benefits over physical or cognitive training alone (18,20,29,133). Several studies have also
examined the effects of experimentally increasing cognitive demands during physical activity,
commonly referred to as dual tasks (DT) (18,20,29,133), and demonstrated improved DT gait
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73
velocity, balance, attention/inhibition, and global cognition. Importantly, many common
activities are inherently demanding physically and cognitively. Here, we refer to common,
inherently demanding activities as cognitively-demanding physical activities. These activities
require conscious awareness or mindfulness of movements, incorporate continuous internal and
external feedback, adaptation to novel and challenging tasks, and attention to environmental
stimuli (e.g. changing weather conditions, uneven surfaces, reacting to a partner) (29). Tai chi,
yoga, dance, boxing, surfing, and tennis are common examples of these cognitively-demanding
activities (24,29,90,95,129).
Golf is also a cognitively-demanding physical activity. The golfer must negotiate
walking on uneven and often hilly terrain, avoid obstacles (e.g. gopher holes, sand traps), bend
over to place or mark a ball, and produce high-powered swings that require coordination of
anticipatory adjustments in posture and movement while visually fixating a small ball at their
feet. Additionally, while walking, the golfer performs numerous cognitive tasks such as deciding
which club to use, how hard to hit the ball, and how the wind/rain/grass will affect the shot. After
the swing, they must locate where their ball landed, navigate a route to the ball, while also
avoiding encroachment on concurrent play groups. As they walk, they must decipher how far the
next shot will need to be hit, begin incorporating internal and external feedback from their
previous shots, track their score, and strategize to optimize it. Simultaneously, participants need
to be attentive to the social dynamics of the play group (friends or strangers), reconcile feelings
regarding their performance (i.e., disappointment/excitement) and attend to the ever-changing
outdoor environment. Consequently, given the many ways golf uniquely integrates simultaneous
physical and cognitive demands, we hypothesized that participation in a golf training
intervention would improve DT walking performance and cognitive function.
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The relationship between motor activity and cognitive function is not yet fully understood
and is a relatively new area of investigation. Recent work has proposed that motor and cognitive
functions have shared brain circuits, and that both motor and cognitive activities may impact the
underlying functional circuits of the other (103,206). Only a few studies have examined the
influence of a golf intervention on brain structure and function. One of the very first studies
examining golf’s impact on the brain was conducted by Bezzola and colleagues. They examined
the effect of a 40-hr golf training on neural plasticity and motor imagery in 22 middle-aged
participants (40-60 years) using MRI (23,92). Their findings suggested that golf training
increased gray matter volume (primary motor, primary sensory, and pre-motor cortices) and
enhanced neural efficiency in non-primary motor areas during a mental rehearsal of the golf
swing. Shimada and colleagues (24) examined the effects of golf training coupled with a home
exercise program on self-selected gait speed and cognition in 106 healthy, community dwelling
older adults (≥ 65 yrs).They found improvements in story memory, but no changes in word recall
or executive control measures or self-selected gait speed. Lastly, Jansen and Schachten
investigated the impact of a 10-week golf intervention with 21 stroke survivors. Participants
improved in visual imagery (mental rotation test), but not working memory(26). Thus, we are
expanding upon these previous golf studies by assessing DT gait performance, fluid cognition,
and episodic memory in older military Veterans, of whom are at higher risk for poorer health
outcomes and cognitive decline than non-Veterans (204,205).
To date, no studies have examined the impact of golf training on DT gait performance
(walking while performing a cognitive task). DT gait performance is both a clinically meaningful
and scientifically valuable metric because it is sensitive to the interaction of concurrent motor
and cognitive function. It can be argued that nearly all mobility-engaging activities include
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75
cognitive demands, such as walking while conversing with another person or on a cell phone,
crossing the street while monitoring the flow of traffic or navigating the aisles in a crowded
market. It is posited that concurrent ambulatory activity and cognitive tasks also interfere with
each other by competing for shared neural resources, and that the competition contributes to
reduction in gait speed (207). A deeper understanding of DT gait performance is important in
part because evidence indicates that age-related decline in DT gait performance is associated
with fall risk (104,105,208), and DT performance is an important measure for assessing older
individuals’ overall function (4,105,209). Golf offers many opportunities for walking while
performing cognitive tasks, with the possibility of improving DT gait performance.
The purpose of this study was to determine if a 12-week golf training program could
significantly improve DT gait performance and cognition. To this end we examined 3 DT gait
parameters (speed, stride length and cadence), and 2 measures of cognition (fluid cognition and
episodic memory) pre and post golf training. In this first study, our intervention was specifically
limited to older military Veterans, as it has been shown they are at higher risk for poorer health
outcomes and cognitive decline than non-Veterans (204,205). To control for test-retest effects,
participants in the intervention group (INT) were age-, sex-, education, activity-level-matched to
a control group (CON). We hypothesized that the INT group would demonstrate significantly
greater improvements in fast DT gait performance, fluid cognition and episodic memory
compared to the CON group.

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Methods
Experimental Design
The present study is a component of the Golf Intervention for Veterans Exercise (GIVE)
study, a Phase I intervention study designed to assess the safety, feasibility, and efficacy, of a 12-
week golf training program specifically targeting older military Veterans owing to their higher
than usual group risk for poorer health outcomes and cognitive decline (195,204,205,210). All
baseline and follow-up testing for the INT group occurred within 2 weeks prior to the start and
within 2 weeks after completion of the 12-week golf training program, respectively. At the
completion of the intervention study, a CON group was added to control for potential learning
effects in pre- and post-intervention testing. Follow-up testing for CON participants occurred 13
weeks after the baseline testing. The Institutional Review Boards of the University of Southern
California and Veterans Affairs West Los Angeles Medical Center approved the study, and the
University of Southern California board approved the later addition of the CON group.
Recruitment and Screening
Power analyses were performed with G*Power 3 (Brunsbüttel, DE) (211) using pilot data
from four individuals to determine the appropriate sample size. Based upon this analysis, it was
estimated that10 participants were needed to observe pre to post intervention changes with an
estimated power of 80% and a significance level set at 0.05. We accounted for participant
dropout by enrolling 12 INT participants in the GIVE study. Participants in both the INT and
CON groups were recruited through physician referrals, word-of-mouth networking, flyers, visits
to community centers and classes on and off Veterans Administration campuses. All participants
were screened in person or over the telephone for eligibility, as detailed elsewhere (195). All
participants were between 60-80 years old, free of any known physical or cognitive disabilities
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77
and could walk independently. Exclusion criteria were applied to both groups and included any
neurological, musculoskeletal, autoimmune, symptomatic/uncontrolled cardiovascular, or other
medical condition that may affect gait or limit physical activity. Individuals were also ineligible
if they did not obtain approval their primary care physician to participate in the golf training
program. Each week, all participants were asked about their current health status and usual
physical activity levels. If eligibility was not maintained throughout the intervention, participants
were removed from the study.
Participants
Intervention Group (INT)
Twelve healthy, community-dwelling older military Veteran males (60-80 years)
participated in the golf training program (age 70.4 ± 4.8 years, height 1.77 ± 0.06m, mass 100.9
± 24.8kg). All were considered current non-golfers: 8 had never played golf, 2 had played <2
times in the past 5 years, and 2 played less than 5x in the past 20 years.
Control Group (CON)
Ten additional, community-dwelling males (age 68.2 ± 4.0 years, height 1.80 ± 0.1m,
mass 83.6 ± 11.5kg), who had never played golf, were recruited, screened for inclusion and
exclusion criteria, and matched to individual INT participants. CON participants were matched
for sex, age (± 3yrs) and education level (college/no degree, <16yrs; bachelor’s degree, 16yrs; or
graduate degree, >17yrs). Participants were also matched for physical activity level (inactive,
light, moderate, heavy) based on the PEPI Physical Activity Scale (212). Four of the 10 CON
participants were military Veterans. CON participants were requested to live “life-as-usual” and
maintain their baseline physical activity during the 12-weeks between baseline and follow-up
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78
testing. To monitor this request, weekly reminders were provided via text or phone call
throughout the 12 weeks.
Golf Intervention Training Program
Within 2 weeks of baseline testing, INT participants began the 12-week golf training
program, led by a Professional Golf Association (PGA) instructor with 40+ years of teaching
experience. The intervention was designed to safely and effectively teach older non-golfers to
become independent golfers by the end of the golf training program, and a more detailed
description has been published (195). In brief, it consisted of two, 90-minute sessions per week,
at the Heroes Golf Course on the West Los Angeles Veterans Administration campus. In order to
prepare for the physical demands of golf play, INT participants were instructed in warm-up and
complimentary conditioning exercises for the lower- and upper-body at the start of each session
by certified fitness professionals. During weeks 1-3, exercise warm-up time was 45 minutes, and
was gradually reduced to a 10-minute dynamic warm-up in weeks 7-12, as golf play increased
(for complete protocol, see DuBois etal., 2019). Golf instruction also began during weeks 1-3,
and started with swing training (driving, chipping, pitching and putting). Week 4 the participants
began playing 2 holes of the course, and in weeks 5-12, they progressively increased the number
of holes played. During the final intervention week, they completed the entire 9-hole course. INT
participants were instructed to not practice between sessions.
Physical Activity Levels
Participants were requested to maintain physical activity levels during the study. Physical
activity logs were completed at baseline and follow-up data collections, these logs recorded the
minutes spent in structured exercise time during a “typical week in the last month.” (196) The
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79
minutes of weekly structured exercise time, outside of the intervention, were totaled for each
participant.
Testing Procedures
Laboratory Gait Testing
All participants performed multiple walking trials in the USC Jacquelin Perry
Musculoskeletal Biomechanics Research Laboratory. Participants were prepared for instructed
data collection, then instructed to “walk as fast and safe as possible, without running” along a
10m pathway. Participants performed 5-10 single-task (ST) gait trials. Participants were then
instructed to “walk as fast as safely possible while also counting backwards by 3’s” from a
computer-generated random number between 150 and 350. This procedure is commonly used for
DT assessment in aging research (98). A research associate demonstrated the task to ensure
participants understood the instructions.
All trials were recorded over the middle 6m distance of the pathway and included 1.5m
acceleration (walk-in) and .5m deceleration (walk-out) distances for analyses. Quantification of
ST and DT gait trials was performed using a standard lower-extremity marker set (197) to track
kinematics for all leg segments and pelvis bilaterally using a 10-camera Qualisys Oqus 5 motion
analysis system (Qualisys Inc, Gotëborg, SE). Marker coordinate data were collected at 60 Hz
and filtered with a 4
th
order low-pass Butterworth filter with a 6 Hz cut off. Gait events,
including gait speed, stride length, and cadence were calculated and processed using Visual3D
software (C-motion, Inc. Rockville, MD). Stride length measured the distance between
consecutive heel strikes in the same leg and cadence equaled the number of heel strikes for both
legs per unit time, e.g., steps per minute.

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Cognitive Testing
Cognitive testing took place in a well-lit, quiet, private consultation room to ensure
confidentiality and no distractions. Participants confirmed that they could hear and see all verbal
and visual instructions clearly. They were asked to turn off or "silence" their communication
devices for the duration of the session. Two cognitive tests were administrated, the California
Verbal Learning Test 2
nd
Edition (CVLT-II) and the National Institute for Health Toolbox
Cognition Battery (NIH-C). The CVLT-II is a 16-word recall test, standardized and norm-
referenced to a US population sample (213). It provides a comprehensive assessment of verbal
learning and episodic memory. The CVLT-II Standard Form (PsychCorp, Pearson, Inc) was
administered orally by a research assistant who recorded answers on the test’s standardized form.
Three parameters were evaluated: 1) immediate word recall summed over 5 trials (CVLT-IR), 2)
short-delay recall following a 3-min distraction (CVLT-SD) and 3) long-delay recall following a
20-min distraction (CVLT-LD). During the 20-min delay, participants completed self-report
health forms.
The NIH-C is a comprehensive battery of neuropsychological measures that assesses
cognitive function.(214–216) It was administered using an Apple iPad Air MD785LL, as
recommended by the developers. The test battery generates a Fluid Cognition Composite Score
(NIH-FC) based on 5 separately scored tests: 1) executive control, i.e., attention and inhibition,
2) episodic memory, 3) working memory, 4) cognitive flexibility and 5) processing speed.(31)
The NIH-C is valid and reliable (214,215), and fully-adjusted for age, sex, and education levels.
Data and Statistical Analyses
The first 3 successful ST and DT gait trials with a similar gait speed (±5%) were used for
analyses. Average stride length and cadence were calculated from the same 3 trials. To quantify
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81
the cost or effect of the cognitive task on gait, we calculated a cost function equal to the
difference in average gait speed between ST and DT trials, then normalized to the ST gait.
Average DT cost percentage (DTC%) was calculated using the following equation: ((ST gait
speed – DT gait speed) / ST gait speed)*100 (103).
CVLT-IR, CVLT-SD, and CVLT-LD data (total number of recalled words per recall
condition) for were analyzed using the CVLT-II Software package provided by PsychCorp®.
NIH-FC data was analyzed using software provided by the HealthMeasures Company, the
official distribution center for NIH-C. T-Scores, corrected for education, gender, and
race/ethnicity and normalized to a mean of 50 and SD of 10, were used in the analyses.
Baseline characteristics were compared between groups using independent t-tests or c
2

tests for continuous and categorical variables, respectively. Training effects were tested using a
two-factor mixed-model ANOVA for comparisons of all outcome measures. In specific, we
tested for differences between groups (INT, CON), and within-subjects over time (PRE, POST).
In the event of a significant interaction, post-hoc paired t-tests were performed to identify
significant within-subject and between-subject differences. Pearson’s product-moment
correlation coefficients (r) were calculated to determine the association between changes in DT
gait speed and changes in DT stride length. Means, standard deviations (SD) and effect sizes
(ES) are reported. To interpret the strength of differences, results for ES are presented as partial
η
2
values (ANOVA) and Cohen’s d (t-tests).(217) Our interpretations of effect size are as
follows; partial eta squared (η
2
) ES for ANOVA: small: ≥0.01 medium: ≥0.06 and large: ≥0.14.
Cohen’s d ES for paired t-tests: small: ≥0.2, medium: ≥0.5 and large: ≥0.8. Data analysis was
performed using PASW Statistics (Version 18, IBM Corp., Chicago, IL). Significance level was
set a priori at α=0.05.
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Results
Twenty-five participants were recruited to participate in the intervention (Fig. 1), after
passing a phone screening and receiving medical clearance, 12 were consented and enrolled into
the GIVE study. All 12 participated the entire 12 weeks of the golf intervention, but 2
participants did not meet inclusion criteria at the post-test session, reducing the final analyses to
results for 10 participants. One participant (age: 78, education: 18yrs, race: African American,
physical activity: moderate) was removed because of high blood pressure at the post-test session.
The other participant (age: 69, education: 13yrs, race: African American, physical activity: low)
was removed because he reported knee pain due a non-study-related injury. Importantly, there
were no golf-related adverse events during the study and the average within-subject attendance
rate was 21.8 ±1.94/24 sessions (91%). Nineteen potential participants were recruited for the
control group. Eleven passed the phone screening, however, one opted out. Thus, 10 participants
were consented, enrolled in the control group, and completed both pre- and post-test sessions
(Fig. 1).
Baseline demographic characteristics (Table 1) did not different between groups
(p>0.05), with one exception for race/ethnicity (p<0.02), owing to an absence of African
Americans and twice the number of Caucasians in the CON group. As previously noted,
participants were matched for activity level (Table 1). The amount of physical activity (minutes)
reported in daily logs did not differ between groups, F(1, 18)=0.42, p=0.84, η2=0.002. or
between the 2 time points, e.g., PRE and POST, F(1, 18)=0.31, p=0.86, η2=0.02. There was no
interaction between group and time, F(1, 18)=0.23, p=0.64, η2=0.01. Activity logs indicated INT
participants engaged in physical activity an average of 150.0 ±104.4 min per week prior to onset
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83
of the intervention and 157.7 ± 93.0 min/week post intervention; CON participates engaged in an
average of 148.0 ±50.3 min/week at the pre-test assessment and 144.7 ± 57.9 min/week post-test.
Dual-Task Gait
As expected, participants walked slower during DT compared to ST trials. Average DT
gait speed was approximately 0.3-0.4 m/s slower during DT gait in the INT group and 0.2 m/s
slower in the CON group, between both time points in (Table 2).
Comparisons for average DT gait speed indicated that there was not a main effect for
group (F(1, 18)=1.6, p=0.23, η
2
=0.08); however there was a significant effect for time, F(1,
18)=5.6, p=0.03, η2=0.24), and a significant interaction effect, F(1, 18)=8.2, p=0.01, η
2
=0.31
(Table 2). As illustrated in Fig 2a, post-hoc paired t-tests confirmed that DT gait speed increased
by 9.9% for the INT group (p=0.001, d=1.52) but did not change in the CON group (p=0.88,
d=0.07).
DT stride length was greater following golf intervention in the INT group, but was
similar for PRE and POST test trials in the CON group (Fig. 2b). Comparisons indicated there
were no main effects for group, F(1, 18)=0.62, p=0.44, η
2
=0.03, or between time points, F(1,
18)=2.0, p=0.17, η
2
=0.10;, however, there was a near-significant trend and large effect size for
the interaction between group and time, F(1, 18)=3.9, p=0.06, η
2
=0.18. Post-hoc paired t-tests
confirmed that DT stride length was significantly greater (4.3%) at POST testing for the INT
group (p=0.003, d=1.30) but did not change for the CON group (p=0.94, d=0.09) (Fig. 2b).
Pearson correlation analysis indicated there was a predictable relationship between
changes in DT gait speed and changes in DT stride length and that greater improvements in gait
speed were associated with larger changes in stride length (r=0.65, p=0.04).
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84
In regards to DT cadence, there were no significant effects for group, F(1, 18)=1.7,
p=0.09, η
2
=0.09, between time points, F(1, 18)=0.86, p=0.37, η
2
=0.05 or the interaction between
group and time, F(1, 18)=1.7, p=0.21, η
2
=0.09 (Table 2).
DT cost percentage, the relative impact of the cognitive load during DT trials compared
to ST trials, was also similar between and within groups PRE and POST testing (see DTC%,
Table 2). Comparisons confirmed there were no significant main effects for group, F(1, 18)=2.8,
p=0.11, η
2
=0.13, between time points, F(1, 18)=0.30, p=0.59, η
2
=0.02, or the interaction between
group and time, F(1, 18)=0.19, p=0.67, η
2
=0.01.
Cognitive Performance
CVLT-II
On average, participants in both groups recalled more words during immediate recall at
the POST time point than PRE time point (CVLT-IR, Table 2). The 2x2 mixed ANOVA
revealed there was no effect for group, F(1,18)=3.2, p=0.09, η
2
=0.15, however the main effect
for time points (PRE, POST) was significant (F(1,18)=8.3, p=0.01, η
2
=0.32). The interaction
between group and time was not significant, F(1,18)=0.25, p=0.62, η
2
=0.01.
Participants also recalled more words following a short delay during POST testing
(CVLT-SD, Table 2). The two-factor mixed-model ANOVA indicated there was no effect for
group, F(1,18)=0.31, p=0.58, η
2
=0.02. There was again a significant effect for the 2 time points,
F(1,18)=16.3, p<0.001, η
2
=0.48. The interaction between group and time was not significant;
however, there was a large ES, F(1,18)=3.3, p=0.09, η
2
=0.15.
A-priori independent t-test analyses indicated there were group differences in CVLT-LD
scores at baseline; the INT group recalled fewer words than the CON group (Fig 2c). To account
for the baseline difference, the ANOVA for CVLT-LD was performed using a covariance
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85
analysis that accounts for baseline values. Accordingly, the two-factor mixed-model ANOVA
indicated there was no group effect, F(1,17)=0.001, p=0.97, η
2
=0.0. Whereas, there were
significant effects for time points, F(1,17)=6.7, p=0.02, η
2
=0.28, and the interaction between
group and time, F(1,17)=4.4, p=0.05, η
2
=0.20. Post-hoc analyses revealed that CVLT-LD scores
increased by 46% in INT (p<0.001) with a large ES (d=0.90). CVLT-LD scores for the CON
group did not change (p=0.26, d=0.38).
NIH-FC
Participant scores on the NIH fluid cognition did not differ between groups at baseline
(Table 2). Two-factor mixed-model ANOVA comparisons revealed that fluid cognition scores
did not differ between groups, F(1,18)=0.18, p=0.68, η
2
=0.01). Whereas, NIH-FC scores differed
between PRE and POST time points, F(1,18)=14.2, p=0.001, η
2
=0.44, and the interaction
between group and time approached significance, with a large ES F(1,18)=4.0, p=0.06, η
2
=0.18.
Post-hoc t-tests indicated that the INT group scores improved by 15.3% (p=0.01) with a large ES
(d=0.90). NIH-FC scores did not change for the CON group (p=0.07, d=0.66) (Fig. 2d).
Discussion
The purpose of this study was to determine if a 12-week golf training program could
improve DT gait and cognitive performance in healthy older Veterans. Given the complex
interweaving of physically- and cognitively-demanding skills performed when learning to play
golf, we reasoned that the training program would yield improvements in a DT activity that
included a cognitive demand. Thus, in this study we tested the hypothesis that a group of older
Veterans (INT participants) would improve on measures of DT gait and cognitive performance
tested prior and after a golf training intervention. To control for possible learning effects at
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86
POST-testing, a quasi-experimental control group was subsequently added, and we predicted that
POST-test improvements in INT performance would exceed those for the CON group.
Collectively, several outcome measures provided support indicating that the 12-week golf
training program was associated with significant improvements in DT gait and cognitive
performance. Comparisons for DT gait PRE and POST intervention indicated INT participants
exhibited a greater DT gait speed, equivalent to an approximately 10% gain in performance, and
a greater DT stride length, 4% on average. Comparisons for cognitive measures indicated INT
participants exhibited greater long-delay episodic memory and fluid cognition scores, with
average gains of 15-45%. Further, effect sizes for comparisons (η
2
, ES) ranged from medium to
large. CON participants, in contrast, exhibited no changes in PRE to POST measures for DT gait
speed, stride length, long-delay episodic memory scores, or fluid cognition scores.
Examination of the gains in DT gait speed for INT participants suggest the improvements
can be attributed to the increases observed in DT stride length. Correlational analyses identified a
strong, positive correlation between the change in DT gait speed and the change in DT stride
length. DT cadence, in contrast, did not change for either group. Our results and interpretation
are also consistent with previous gait studies indicating that older adults tend to preferentially
increase stride length over cadence when required to walk at faster speeds (64,210). Increases in
gait speed and in stride length have been associated with improved muscle strength and reduced
risk for falls (64). Interestingly, there were no changes in the cognitive cost of DT gait for either
group. DTC% reflects the difference between ST and DT performance in relationship to the ST
performance. The INT group improved both ST and DT gait speed, while CON group walked at
comparable speeds during ST and DT gait at both time points. These results suggest that the
increases in DT gait speed were driven primarily by changes in stride length and not by
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87
improvements in cognitive variables underlying the task of counting backwards. However, it
remains to be investigated whether DT gait performance improvements might also be attributed
to improved cognitive abilities, such as divided attention or task switching, as reflected by the
NIH-FC improvements (47).
We posit that the multi-tasking activities experienced during the 12-week golf
intervention contributed to the improvements in DT gait and cognitive measures observed in the
INT group. Golf play engages multiple cognitive skills during task execution, including working
memory, divided attention, and planning (98,207). Participants must remember to initiate,
correctly execute and sustain or complete both tasks simultaneously. Throughout a session of
golf play, there are many opportunities for learning and performing DT activities. For example,
while walking from one hole to the next, one must decide which club to use, strategize for the
upcoming shot, decipher environmental conditions, attend to obstacles along the path (gopher
holes, sand traps), and carry on a conversation with a partner. Golf play also requires physical
and motor fitness to walk the course, perform high-powered swings, and bend over to pick up or
place the ball. Activities, such as golf, can produce improvements in physical and/or motor
fitness, including aerobic capacity, strength, balance, agility, coordination, and flexibility (119),
gains that can directly lead to improvements in daily DT activities demanding attention and
information processing (79).
Our current results confirm and extend the findings of previous golf interventions in two
areas, cognitive outcome measures and training design. Shimada and colleagues (24), in a
randomized controlled trial, examined the effects of golf training on cognition in healthy,
community dwelling older adults (age 65+). Following 24 weekly training sessions lasting 90-
120 min, participants showed improvements on one of two memory measures administered, but
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88
no improvements in attention, executive function or processing speed scores, compared to
controls. In the present study, improvements were demonstrated in episodic memory and fluid
cognition (as measured by the CVLT and NIH-FC, respectively). It is difficult to directly
compare the Shimada et al. study’s findings with the current study due to methodological
differences in the cognitive measures administered. Nonetheless, combined, the two studies
provide a broader foundation for exploring more selectively the cognitive effects of DT training
programs in older populations.
The current study also extends the findings of Shimada et al, by examining a different
type of golf intervention strategy. While both studies provided a framework of 24 golf-training
sessions, participants in our study practiced twice-weekly, and 18 of the sessions were on the
golf course. In the Shimada study, golf instruction was provided once weekly and only 10 of 24
sessions were on the golf course. It may also be relevant that in the current study, participants
trained in groups of 4, compared to groups of 7-10 individuals in the previous study. These
differences point to the importance of examining the impact of different dosing structures to
more effectively target cognitive improvements in DT training programs such as golf.
Differences aside, the results from the current study confirm that the golf intervention has
positive effects on memory and also extends the cognitive benefits to include executive control,
processing speed, and working memory, all components of fluid cognition.
Currently, there is insufficient knowledge of the neurological underpinnings that may
account for the cognitive impact of DT activities involving gait, and golf in particular.
Neuroimaging studies have suggested golf training may impact cortical connectivity involving
the fronto-parietal network (72). Based on comparisons of resting-state fMRI in professional
golfers and non-golfers, investigators have proposed that professional golfers develop enhanced
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89
connectivity between cerebellum and frontal, temporal, and parietal lobes associated with motor
planning (72).

Evidence has also been reported on structural (23) and functional (92) MRI brain
changes following a 40-hr golf training program in which gray matter volume increased in
golfers but not controls, with increases specific to areas associated with spatial awareness and
motor learning.
Limitations
Our focus from the outset was to address concerns regarding important health disparities
in older Veterans, thus producing some limitations when interpreting or extrapolating our
findings. For example, the sample size was small (INT = 12; CON = 10), however, it was based
upon earlier pilot data from older Veterans and our significant findings had large effect sizes.
The INT group was comprised of only older male military Veterans, so results may not directly
extrapolate to older female or non-Veteran populations. Although the CON participants were
matched to the INT participants for sex, age, education and physical activity levels on an
individual basis, CON participants included only 4 Veterans, and groups assignments were not
randomized. Given known health disparities reported for Veterans (204,205), there may be
important differences between the groups that impacted the results, possibly masking even
greater effect sizes in INT measures. We note, for example, that groups were not matched for
Veteran status or race. Although ANOVA comparisons found no significant main effects for
group, there was an overall pattern of larger baseline measures for the CON group. However,
INT intervention resulted in performance increments that reached or nearly-reached those for the
CON group, further supporting that the intervention had a clinically-meaningful impact.
Additionally, the study design does not allow us to determine if the adaptations persist over time.

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90
Conclusion
In conclusion, given the scarcity of studies investigating the effects of golf interventions
on physical and cognitive performance in older adults, this study adds to the current small body
of evidence that these cognitively-demanding types of interventions can improve DT gait
performance and cognitive function. The intervention yielded a high adherence rate, likely
important to these outcomes. To advance our understanding of the relationship between DT
training in general, and in golf interventions specifically, as well as its impact on both physical
and cognitive performance, future studies should include randomized and controlled
experimental designs exploring multiple intervention strategies to account for the cognitive,
social and physical aspects of cognitively-demanding physical activities. To gain insight into the
synergies between activity and cognitive demands, future studies examining golf should also
include structural and functional neuroimaging and neurotrophic measures in order to tease-out
the mechanisms by which neurological improvements are occurring. Investigators should also
consider populations with lower physical capacity or impaired cognitive function. As a
cognitively-demanding physical activity, the present findings suggest golf may now be included
on the list of exercise activities that can improve important health outcomes in older adults.

Acknowledgements
Much appreciation goes to our participants that dedicated their time to the GIVE Study, James
Dennerline for leading the golf training, and Urban Golf Performance and Erin Blanchard for
their contribution to developing the complimentary exercises.

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Figure 5.1. Intervention and Control Group Recruitment Flowchart.

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Figure 5.2. Pre- and post-intervention changes in dual-task gait and cognitive measures.

Figure. 5.2 Mean ± SD. a: Average dual-task gait speed pre- and post-intervention for
intervention (INT) and control (CON) groups. *significant group x time interaction (p=0.01). b:
Average dual-task stride length pre- and post-intervention for INT and CON. *marginally
significant group x time interaction (p=0.06). c: Average CVLT-LD pre- and post-intervention
for INT and CON groups. *significant group x time interaction (p=0.05). d: Average NIH-C
Fluid Cognition pre- and post-intervention for INT and CON groups. *marginally significant
group x time interaction (p=0.06).

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Table 5.1. Baseline Demographic Characteristics for Intervention and Control Group.
Table 5.1. Baseline Demographic Characteristics
Variable
Intervention Group

Control Group
p-
value
N 10

10

Age (years) 69.8 ±4.6

68.2 ±4.0 0.44
Education (years) 14.9 ±1.5

15.4 ±1.5 0.49
Physical Activity Level (n)

0.99
High 2

2

Med 7

7

Low 1

1

Race/Ethnicity

0.02
African American 5

0

Hispanic 1

2

Caucasian 4

8

BMI Score 30.8 ±7.3 25.9 ±3.0 0.09

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Table 5.2. Dual-task Gait and Cognitive Performance Measures for Intervention and Control Groups.
Table 2. Means, SD, ES and p-values for DT Gait and Cognition for pre and post measures in both intervention and control groups.

Intervention group n=10 Control group n=10 Time Group x Time
Variable
Pre Post Pre Post p-value p-value
Gait

ST Gait Speed (m/s) 1.97 ±.38 2.10 ±0.34

2.09±0.23 2.08 ±0.25 0.03 0.02
DT Gait Speed (m/s) 1.62 ±0.28 1.78 ±0.32

1.89±0.35 1.87±0.29 0.03 0.01
DT Stride Length (m) 1.64±0.23 1.71±0.22

175±0.18 1.74±0.11 0.17 0.06
DT Cadence (steps/min) 122.4±12 124.8±11

129.6±16 129.2±15 0.37 0.21
DTC Percentage (%) 17 ±7.8 15 ±7.6

10±9.9 10 ±10.0 0.45 0.82
CVLT (# of words)

Immediate Recall
(5 trials) 41.9 ±8.7 45.7 ±10.9

47.7 ±7.6 53.1 ±8.3 0.01 0.62
Short-Delay Recall 8.4 ±2.8 10.5 ±2.7

9.6 ±1.6 10.4 ±1.5 <0.001 0.09
Long-Delay Recall 8.3 ±2.2 12.1 ±2.3

10.6 ±2.3 11.6 ±1.8 <0.001 0.05
NIH-C T-score

Fluid Cognition 47.2 ±6.4 54.4 ±10.2

48.3 ±6.9 50.5 ±5.9 <0.001 0.06
A two-factor mixed ANOVA was used for all gait parameters. Significance level was set at £0.05 and is noted in bold.
SD:Standard Deviation. ES:Effect size. CVLT:California Verbal Learning Test. NIH-C:NIH Toolbox - Cognition. ST:single-task. DT:dual-task. DTC:Dual-task cost.

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CHAPTER VI
SUMMARY & CONCLUSIONS

The present dissertation investigated how a 12-week golf training program can affect gait
and cognition in older adults. Age-related mobility and cognitive declines are major public health
concerns, entreating clinicians and researchers to discover novel techniques to approach this
ever-increasing challenge. The results of this dissertation study provide evidence that a 12-week
golf training program, can not only attenuate these declines, but actually improve gait
performance and cognitive function in older military Veterans.
The relationship between aging and gait speed is so outstanding, that gait speed has been
called the "sixth vital sign" (2). In older adults, decreased walking speed is associated with
poorer health outcomes, disability, hospitalization, increased fall risk, cognitive decline, and
mortality (2,3,33,35,36). Gait dysfunction in older adults, leading to slower gait speed, includes
shorter stride length and increased cadence (steps per minute) (52,64,194,218). These age-related
changes in gait have been primarily attributed to the loss of plantarflexor (PF) strength and
power generating capacity (55–60,62,63).
Chapter IV identified spatiotemporal and biomechanical changes underlying the
improved six-minute walk test (6MWT) and single-task (ST) fast gait speed that occurred
following the 12-week intervention. The purpose of the 6MWT is to assess aerobic endurance
(198,219), this is important for day-to-day functional activities such as walking through
neighborhoods, shopping malls, grocery stores and parking lots, or even sightseeing on vacation.
Golf can be considered a moderate- to high-intensity aerobic activity in older males (21,22,220),
and the improvements observed in our golf intervention participants during the 6MWT suggests
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that their aerobic endurance improved over the 12-week duration. Those in the analysis, on
average, increased their ST fast gait speed by increasing their stride length, and not cadence, to
meet the demands of the fast walking task. In addition, there was an increased hip extensor
moment during the initial stance phase that was accompanied by an increased peak power
demand at the hip. The increased hip joint kinetics accompanying the changes in 6MWT and fast
gait speed are likely related to the physical demands of the 12-week golf program, which
included walking the golf course, high-powered swings and bending /squatting activities. Golf,
as a multimodal exercise, is effective in improving ST fast gait performance in older adults
which may reduce the risk for poor health outcomes such as disability, falls, and hospitalization.
With age comes diminished capacity for dual-task (DT) performance and cognitive
function (102,219). Chapter V details the results of our golf participants increasing their DT gait
speed, DT stride length, episodic memory, and fluid cognition following the 12-week
intervention, compared to a control group. There is much research demonstrating that increasing
DT gait speed and reducing interference costs, through exercise interventions, may lower
participants’ risk for falls, dementia, and keep older adults independent in their communities
(11,104,105,221). These findings are an important addition to the exercise literature by
establishing golf as a multimodal, cognitively-demanding physical activity, capable of improving
DT gait and cognitive performance (see Chap. III). Golf is an activity that inherently combines
both physical and cognitive demands simultaneously into one activity. Physical demands of
walking the course, performing squats/lunges to pick up or place the ball and high powered
swings fulfill the traditional “multimodal” components of endurance, strength, balance,
flexibility and movement velocity recommended by the latest guidelines set forth by the US
government (28,151). Additionally, cognitive demands of golf comprise of navigating the
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97
course, locating and tracking the ball, focusing attention on the ball, filtering out distractions,
utilizing eye-hand coordination, calculating the intensity and distance of the next shot; all while
incorporating the feedback they received (internal or external) from the previous shots. These
cognitive demands may be the underlying mechanism of the improvements observed in our golf
intervention participants’ episodic memory and fluid cognition; both of which are especially
vulnerable to age-related decline.
It has been long confirmed that there is an association between physical activity levels
and cognitive performance (8,12,18,120). Many studies have investigated exercise modalities
such as treadmill, bike, balance, and resistance training. This is one of the first studies to reveal
that golf training can improve cognition in older adults, Shimada et.al. (24) also examined how
golf training impacts cognition and provided evidence that it can improve logical memory. Our
present findings support a growing number of studies investigating how multicomponent
(combined physical and cognitive training performed sequentially or simultaneously) and
cognitively-demanding physical activity exercise interventions can result in improved cognition
in older adults. As mentioned earlier, a typical session on the golf course is comprised of many
cognitive demands: planning, strategizing, maintaining focus and attention, inhibiting
unimportant stimuli, keeping count of one’s own and opponent’s score, all while performing
physically demanding tasks: walking hilly terrain, high-powered swings, bending over to
place/retrieve the ball. It is now well established that many neural pathways and processes
involved in motor function overlap with cognitive functions of executive control, attention and
inhibition and working memory (79,206,222). The link between exercise training and improved
cognitive performance may be due to improving several underlying neurobiological and
physiological mechanisms (23,92,223–225): increased neuroplasticity (brain’s ability to adapt),
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98
increased synthesis of neurotransmitters and neurotropic factors (BDNF, NGF), increased
synaptogenesis, and increased synaptic long-term potentiation (communication strength between
neurons). Chapter V provides convincing data that participation in a 12-week golf training
program may improve gait and cognitive performance in older adults through attenuating the
declines in DT performance, episodic memory, and fluid cognition that typically accompany
aging.
In this quasi-experimental study, the intervention (INT) group was comprised of all older
male military Veterans, while the control (CON) group consisted of 40% older male military
veterans. Based on this, results may not directly extrapolate to older non-Veteran populations.
Military Veterans share a strong sense of comradery, are very dedicated to commitments they
make, and are highly motivated. Perhaps as a result of this combination of factors, participants in
the INT group demonstrated high enthusiasm to complete the entire program, resulting in a high
adherence rate. These factors also may have attributed to the large improvements observed from
pre- to post-intervention. Although ANOVA comparisons found no significant main effects for
group, there was an overall pattern of larger baseline measures for the CON group. In spite of
this, participation in the golf intervention resulted in improved performance increments that
reached those for the CON group at follow-up testing, further supporting that the intervention
had a significant impact. Future studies comprised of a Veteran-only population are
recommended and may result in larger pre-post training effects than observed in the current
study.
In conclusion, this dissertation establishes golf as a cognitively-demanding physical
activity that can impact gait and cognitive performance of older military Veterans, all while
being safe, effective and accessible (195). Many people dread getting older, as it is typically in
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99
conjunction with the so-called “inevitable” declines in mobility and cognitive function, however,
this does not have to be the final outcome. These studies reinforce the evidence that we are not
held captive by our genetics but by modifying one’s lifestyle behavior (epigenetics) one can
optimize aging, while attenuating age-related declines (88). Scientific inquiry of golf’s impact on
overall health and aging is in its nascent stages. Future research is needed to explore its effects in
various populations, in particular those with cognitive impairment. The need to delay the onset of
dementia in this population is crucial as more and more are diagnosed with cognitive impairment
and dementia. Exercise interventions that are cognitively stimulating have the potential to do just
this.

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Abstract (if available)

Abstract Gait speed and cognition are important predictors of successful aging. Both slow gait speed and cognitive decline are associated with poor health outcomes, including hospitalization, falls, institutionalization and death. Exercise interventions can improve both gait and cognitive performance in older adults. Together in its entirety, the purpose of this dissertation was to examine the influence of a 12-week golf intervention on walking performance and cognition in older adults. Golf training, as a multimodal, cognitively-demanding physical activity, may have pronounced effects on walking ability and cognition. In the past, studies investigating golf have typically examined the performance of golfers (fitness, golf swing velocity, ball velocity, upper and lower-body mechanics during the golf swing) and few have examined the overall functional and health benefits that come from playing golf (see Chap. III). It is for this reason that we developed an intervention to safely and effectively teach older adults to become independent golfers via a 12-week golf training program, which may be an exercise modality that has pronounced effects on gait and cognition. ❧ Although golfing is commonly viewed as a “recreational activity” and not “exercise”, recent reports suggest that the physical demands of golf (e.g. navigating the course, walking hilly terrain, bending over, swinging, weight-shifting) maintain/increase strength, flexibility, power-production, balance, and aerobic fitness in older adults. Moreover, golf is cognitively demanding, as evidenced by the preparation, strategizing, measuring, and execution phases of the game. ❧ The Golf Intervention for Veterans Exercise (GIVE) study was a Phase I, 12-week golf training intervention study. All participants came to the USC Jacqueline Perry Musculoskeletal Biomechanics Research Laboratory for baseline testing within 2 weeks of the start of the 12-week intervention and returned to the lab within two weeks of the completion of the intervention for follow-up testing. Those in the intervention group (INT) participated in a 12-week golf training program (2 × weekly

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Asset Metadata

Creator Marcione, Nicole A. (author)

Core Title Effects of a 12-week golf training program on gait and cognition: the Golf Intervention for Veterans Exercise (GIVE) study

School School of Dentistry

Degree Doctor of Philosophy

Degree Program Biokinesiology

Publication Date 11/13/2019

Defense Date 05/30/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag aging,cognition,dual-task,exercise intervention,gait,OAI-PMH Harvest

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Salem, George (committee chair), Bradley, Nina (committee member), Melrose, Rebecca (committee member), Powers, Christopher (committee member)

Creator Email marcione@usc.edu,nmarcione@email.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-232701

Unique identifier UC11673721

Identifier etd-MarcioneNi-7916.pdf (filename),usctheses-c89-232701 (legacy record id)

Legacy Identifier etd-MarcioneNi-7916.pdf

Dmrecord 232701

Document Type Dissertation

Rights Marcione, Nicole A.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA