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Effect of Music-Based Multitask Training on Gait,
Balance, and Fall Risk in Elderly People
A Randomized Controlled Trial
Andrea Trombetti, MD; Me´lany Hars, PhD; Franc¸ois R. Herrmann, MD, MPH;Reto W. Kressig, MD; Serge Ferrari, MD; Rene´ Rizzoli, MD Background: Falls occur mainly while walking or per-
group. Balance and functional tests improved compared forming concurrent tasks. We determined whether a mu- with the control group. There were fewer falls in the in- sic-based multitask exercise program improves gait and tervention group (incidence rate ratio, 0.46; 95% confi- balance and reduces fall risk in elderly individuals.
dence interval, 0.27-0.79) and a lower risk of falling (rela-tive risk, 0.61; 95% confidence interval, 0.39-0.96). Similar Methods: We conducted a 12-month randomized con-
changes occurred in the delayed intervention control trolled trial involving 134 community-dwelling individu- group during the second 6-month period with interven- als older than 65 years, who are at increased risk of fall- tion. The benefit of the intervention on gait variability ing. They were randomly assigned to an intervention group (n = 66) or a delayed intervention control groupscheduled to start the program 6 months later (n = 68).
Conclusion: In community-dwelling older people at in-
The intervention was a 6-month multitask exercise pro- creased risk of falling, a 6-month music-based multi- gram performed to the rhythm of piano music. Change task exercise program improved gait under dual-task con- in gait variability under dual-task condition from base- dition, improved balance, and reduced both the rate of line to 6 months was the primary end point. Secondary outcomes included changes in balance, functional per-formances, and fall risk.
Trial Registration: clinicaltrials.gov Identifier:
NCT01107288
Results: At 6 months, there was a reduction in stride
length variability (adjusted mean difference, −1.4%;
P Ͻ.002) under dual-task condition in the intervention Published online November 22, 2010. group, compared with the delayed intervention control doi:10.1001/archinternmed.2010.446 FALLSARECOMMONANDDEV- whenperformingconcurrenttasks,such
or cognitive tasks.11,12 Gait variability (ie, stride-to-stride fluctuations in walking), particularly during dual-task walking con- least 1 fall, and half of those fall repeat- ditions, can objectively characterize gait edly.1,3-5 This problem will continue to grow as the number of older adults increases over flecting a more unstable gait pattern, that the coming decades.6 Thus, preventing falls in turn leads to an increased risk of fall- in elderly individuals is a major concern.
ing.1,13-17 There is little information regard- Measures to reduce falls are often of lim- ing effective measures to improve or even Author Affiliations: Division
ited benefit.7 Exercise can counteract key risk factors for falls, such as poor balance, der dual-task conditions in elderly people.
and consequently reduce risk of falling in elderly community-dwelling individuals.7,8 See also
land, in the early 20th century. It is now related article
practiced worldwide in the field of music, as well as dance, theater, and therapy. Prac- titioners are introduced to music’s basic ele- over, older adults are more likely to fall 2010 American Medical Association. All rights reserved.
ous multitask exercises performed to the rhythm of im- ing to a computer-generated list prepared by an independent provised piano music.18 Recently, specific classes for older statistician, without stratification, using a permuted block ran- adults have been developed. The integrated motor and cog- domization design. Allocation assignment was concealed from nitive components are key features of this program, which involves a greater interest for dual- or multiple-task prac-tice than other multicomponent attention-demanding ex- INTERVENTION
ercise forms (eg, Tai Chi). In a cross-sectional study of older,long-term practitioners of Jaques-Dalcroze eurhythmics, The intervention was a structured 1-hour weekly class exerciseprogram led by an experienced instructor. It featured various mul- age-related increase in stride-to-stride variability in a dual- titask exercises, sometimes involving the handling of objects (eg, task context appeared to be attenuated.19 percussion instruments or balls), which became gradually more We conducted a randomized controlled trial to deter- difficult over time.22 Basic exercises consisted of walking in time mine whether a 6-month music-based multitask exercise to the music and responding to changes in the music’s rhyth- program (ie, Jaques-Dalcroze eurhythmics) would im- mic patterns. Exercises involved a wide range of movements and prove gait and balance and reduce fall risk in community- challenged the balance control system mainly by requiring mul- dwelling older adults at high risk of falling. Change in gait tidirectional weight shifting, walk-and-turn sequences, and ex- variability under dual-task condition from baseline to 6 aggerated upper body movements when walking and standing.
months was the primary end point. Secondary end points Subjects in the delayed intervention control group were in- were to assess changes in other quantitative gait and bal- structed to maintain their usual physical and social activities, aswas the early intervention group after the program ended, ie, dur- ance measures, functional test performances, and falls and ing the second 6-month period. Both groups were asked to avoid to determine through a 6-month postintervention fol- any new additional exercise programs during the course of the low-up whether the benefit due to the intervention could study. No instructions were provided to perform any specific ex- ercise outside class time. Adherence to the Jaques-Dalcroze eu-rhythmics program was verified by weekly attendance records.
FOLLOW-UP VISITS
STUDY DESIGN
Participants were assessed by a trained multidisciplinary teamblind to the participants’ group allocations and to information In this 12-month monocenter, randomized controlled trial, sub- from previous evaluations. Functional tests and instrumental jects were randomly assigned to either a music-based multitask gait and balance analysis were conducted using a standardized exercise program or a delayed intervention control group for 6 protocol, as detailed in the following subsection. Interviews col- months (or 25 weeks). The primary end point was assessed at 6 lected sociodemographic characteristics, fall history, nutri- months. During the second 6-month period, the delayed inter- tional status,23 physical activity level,24 and neuropsychologi- vention control group participated in the intervention program, cal status.25-29 All participants also underwent a complete physical while the early intervention group returned to their usual habits (ie, no more intervention). Both groups were assessed at base-line and months 6 and 12. Enrollment began in February 2008,and the follow-up period ended in December 2009. The study ASSESSMENT OF GAIT, BALANCE,
was approved by Geneva University Hospitals ethics committee.
AND FUNCTIONAL PERFORMANCE
All study participants provided written informed consent.
Gait and balance were assessed using an electronic pressure sen-sitive walkway (GAITRite; CIR Systems Inc, Havertown, Pennsyl- STUDY PARTICIPANTS
vania) and angular velocity transducers (SwayStar; Balance Inter-national Innovations GmbH, Iseltwald, Switzerland), respectively.
Participants were recruited in the local community through mul- Gait parameters were collected according to the spatiotemporal tiple strategies, including advertisements in local newspapers.
gait analysis guidelines.30 The subjects were asked to walk at their The inclusion criteria were (1) adults 65 years or older, (2) liv- self-selected usual, slow, and fast speed as a single task. Then, they ing in the community, (3) without previous experience of Jaques- were asked to walk at a self-selected speed and to simultaneously Dalcroze eurhythmics, except during childhood, and (4) at in- count aloud backward by 1 starting from 50, as a dual task, with- creased risk of falling. Participants were considered at risk of out specific instruction to prioritize either task. Coefficient of varia- falls if they met at least 1 of the following criteria: (1) 1 or more tion (CV) was used as a measure of variability for stride time and self-reported falls after the age of 65 years, (2) balance impair- stride length parameters (CV=[standard deviation/mean]ϫ100).
ment as assessed by a simplified Tinetti test with a score higher The relative and absolute test-retest reliability of gait outcome mea- than 2 of 7,3,20 and (3) 1 or 2 criteria of physical frailty.21 Sub- sures was examined in a random sample of 30 study participants.
jects were excluded if their medical history or physical exami- Under the dual-task condition, intraclass correlation coefficients nation revealed (1) a neurological disease associated with mo- (2,1) for gait variability measures were all above 0.68. The stan- tor deficit or an orthopedic disease with a significant impact dard error of measurement values were 1.59% and 0.99% for CV on gait and/or balance that would compromise outcomes as- of stride time and stride length, respectively.
sessment (2) or any other medical conditions that would limit The SwayStar system consists of 2 angular velocity trans- participation (eg, terminal illness). Participants fully depen- ducers worn on the lower trunk.31 Each participant was tested dent on an assistive device were excluded.
for a 2-legged stance task for 20 seconds and a 1-legged stancetask for 10 seconds with eyes open and for 1 dynamic task (ie, RANDOMIZATION
getting up from a chair, sitting down, standing up again, andremaining standing).32 Four outcome variables were calcu- Eligible subjects were randomized to either the intervention or lated for each task, in addition to task duration, ie, 90% range the delayed intervention control group in a 1:1 ratio accord- of both trunk angular displacement and angular velocity, in me- 2010 American Medical Association. All rights reserved.
for 12 months and recorded daily using a diary mailed monthlyto the study coordinator.37 Participants who failed to return the diary or provided incomplete data were contacted by telephone.
SAMPLE SIZE CALCULATION
The sample size was determined using data from a previous study.19 Ninety-six participants (ie, 48 in each group) were needed for a statistical power of 90% to detect a difference between groups at a 2-sided significance level of 5% on the primary outcome gait variability in dual-task condition, assuming that gait variability in this population was 4%. This allowed us to detect a differ- ence of 1% in gait variability between the intervention and the control groups at completion of the first 6-month intervention.
With 10% mortality and 20% dropout rates, a sample size of 130participants was targeted.
STATISTICAL ANALYSIS
All analyses were based on intention-to-treat, with the last value carried forward for missing values. The ␹2 test, t test, or Wilcoxon rank sum test were used, as appropriate, to compare baseline char- acteristics. Changes from baseline to 6 months were summarized asmeansandstandarddeviations.Estimatesofbetween-groupmeandifferences, adjusted for baseline values, were computed, togetherwith 95% confidence intervals (CIs). Analyses of covariance were performed to examine differences in changes across groups, with baseline value as covariate. Because gait velocity may represent a potential confounder when evaluating gait variability,38 additional analyses with adjustments for changes in gait velocity were per- formed for all variability measures. Data were also analyzed at a normalized velocity of 100 cm/s (ie, within the individual rangeof velocities and close to the mean usual gait velocity) using an in-terpolation procedure, pooling the 3 walking conditions under a singletask(ie,self-selectedslow,usual,andfastspeeds),asdescribed elsewhere.39,40 Six-to12-monthchangesweresummarizedasmeansand standard deviations. Crossover analyses were performed using a specific Stata procedure (command pkcross) that enables analy- sis of crossover experiments and provides significance values forsequence, period, intervention, and carryover effects. The data werereanalyzed (1) without adjustment for baseline covariates, (2) using per-protocol analysis of study completers without imputation, and (3) using linear mixed-effects regression models (with Stata “xtmixed” command) to predict the primary end point, with 8 Had declining health4 Had inadequate time for visit, intervention, and visit by intervention interaction as ex- For fall outcomes, log-binomial regression models were used to calculate relative risks comparing both the number of sub-jects with 1 or more falls and subjects with multiple falls (Ն2 falls during the study period) in both groups. The incidence rate ratio for the number of falls was analyzed using a negative binomial regression model. In addition, survival analyses were conducted: hazard ratios were estimated from a Cox propor- tional hazards model for the first fall, and its extension, theAndersen-Gill model,41 for all falls. In these models, subjectswho did not achieve expected follow-up were censored at the Figure 1. Flowchart for enrollment, randomization, and follow-up of study
participants.
All statistical significance tests were 2-sided, and PϽ.05 was considered statistically significant. Analyses were performed using diolateral and anteroposterior directions.33 For functional tests, Stata software version 11.0 (StataCorp, College Station, Texas).
each participant underwent Timed Up & Go34,35 and simpli-fied Tinetti tests.3,20,36 ASSESSMENT OF FALLS
As shown in the flowchart (Figure 1), 241 individuals
Falls were defined as “unintentionally coming to rest on ground, were screened and 134 (56%) enrolled. Of these, 22 (16%) floor, or other lower level.”37 Falls were prospectively monitored and 28 (21%) dropped out of the study at 6 and 12 months, 2010 American Medical Association. All rights reserved.
respectively. There was no difference between groups inthe number of participants with incomplete follow-up.
Table 1. Baseline Characteristics of Participants
Mean attendance rate at the exercise program was 78%and did not vary by group. The attendance rate of the Intervention
Intervention
participants completing the intervention was 83%, 77% Characteristic
of whom attended at least 20 classes (ie, 80% of the classes).
The main reasons for not attending classes included health problems, family constraints, or difficulties related to travel. No major adverse events occurred during the study, and there were no adverse effects, such as falls, cardio- vascular events, or any injury during or following the ex- The mean (SD) age of the participants was 75.5 (6.9) years, and 96% were women (Table 1). Baseline char-
acteristics were identical in both groups, except for height (P=.04), with no differences in study outcomes (Table 2
and Table 3). Participants in both groups displayed simi-
lar baseline fall history profiles in the year before the study.
Completers and dropouts did not differ significantly on Under the single-task condition, intervention group subjects increased their usual gait velocity (adjusted mean difference [AMD], 4.7 cm/s; 95% CI, 0.5 to 8.8; P = .03), and their stride length (AMD, 3 cm; 95% CI, 0.5 to 5.6; P = .02) compared with the delayed intervention control group (Table 2). In the intervention group, the stride time variability improved (AMD, −0.4%; 95% CI, −0.7 to −0.1; Physical activity level, mean (SD), kcal/wk P = .01). When normalized for a gait velocity of 100 cm/s (see the “Methods” section), the change in gait variabil- ity was no longer significant. Under the dual-task con- dition, intervention group subjects increased their stride length (AMD, 3.1 cm; 95% CI, 0.1 to 6.1; P = .04) and de- creased their stride length variability (AMD, −1.4%; 95% CI, −2.3 to −0.6; P Ͻ.002) (Figure 2) compared with
controls. Adjustments for gait velocity changes did not influence gait variability modifications. Other statistical approaches (ie, without adjustment, per-protocol analy- sis as well as mixed-effects regression model) provided similar results in both magnitude and direction for the By comparison with the delayed intervention con- trols, the intervention group improved stance time for the 1-legged stance task (AMD, 0.9 s; 95% CI, 0.3 to 1.6; P = .006) (Table 3) and decreased mediolateral angular velocity (AMD, −4.6 degrees/s; 95% CI, −8.6 to −0.6; P = .02). In the Tinetti and Timed Up & Go tests, the in- tervention group did better than the controls (Table 3).
Compared with the control group, the intervention group experienced fewer falls during the first 6-month pe- riod: the unadjusted incidence rate ratio for falls was 0.46 (95% CI, 0.27 to 0.79; P=.005) and remained similar when adjusted for age, falls history over the previous 12 months, Tinetti test performance, and the number of frailty crite- ria (according to Fried et al21) met (Table 4). The num-
ber of subjects with 1 or more falls was also statistically different between both groups (relative risk, 0.61; 95% CI,0.39 to 0.96; P=.03) with a number needed to treat of 5 Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); FAB, Frontal Assessment Battery; HADS, (95% CI, 2.1 to 34.4). The relative risk for multiple falls Hospital Anxiety and Depression Scale; MMSE, Mini-Mental State Examination; was 0.19 (95% CI, 0.06 to 0.63; P=.007). Using a Cox pro- MNA, Mini-Nutritional Assessment; SF-12, 12-item Short-Form Health Survey.
portional hazards model, we found that the unadjusted haz- Significant difference between groups (PϽ.05).
ard ratio for the time to first fall was 0.53 (95% CI, 0.30 c Five-point Likert scale from 1 (excellent) to 5 (bad).
to 0.94; P=.03) in the intervention group compared with 2010 American Medical Association. All rights reserved.
Table 2. Change in Gait Outcome Measures by Groups
Mean (SD)
Mean (SD)
Baseline
Changes at 6 moa
Adjusted
Changes at 12 mob
Effect,d
Between-Group
P Value
Intervention Intervention Intervention Intervention
Difference
P
Intervention Intervention
Outcomes
Sequence vention
Single-Task Condition
Dual-Task Conditione
Abbreviations: CI, confidence interval; CV, coefficient of variation.
a Changes were calculated as 6-month follow-up minus baseline.
b Changes were calculated as 12-month follow-up minus 6-month follow-up.
c Analyses of covariance on change in measures with the baseline value as covariate.
d Crossover analysis of variance on change in measures using a specific procedure dealing with the analysis of crossover experiments, which provides significance values for respectively sequence, period, intervention, and carryover effects. Ellipses represent nonsignificant values.
e One subject under the dual-task condition had to be excluded from the analysis due to technical failure of GAITRite; CIR Systems Inc, Havertown, Pennsylvania.
the control group. This remained significant after adjust- same period, while the intervention was dispensed, 19 ment for baseline covariates. When comparing the 2 groups subjects (34%) of the former delayed intervention group using an Andersen-Gill model, the unadjusted hazard ra- had at least 1 fall, of whom 6 (11%) had fallen repeat- tio of 0.46 (95% CI, 0.27 to 0.78; P=.004) remained sig- edly, with 28 reported falls. The incidence of falls was significantly reduced during this period of intervention Using a crossover analysis of variance, we found sig- compared with the first 6 months (P = .02), as was the nificant carryover effects for some outcomes, indicating proportion of participants with multiple falls (P = .01).
that several changes in the early intervention group had The reduction in the proportion of subjects with 1 or more been maintained at 12-month follow-up (Table 2 and falls failed to reach significance (P = .06).
Table 3). The improvement in gait variability under dual-task condition was retained 6 months after the interven-tion had ended, as were improvements in 1-legged stance duration and in Tinetti performance. At the 12-monthfollow-up, when both groups had taken part in the in- To our knowledge, this is the first evidence of a revers- tervention program, the crossover analysis revealed im- ibility in age-dependent increase of gait variability un- provements in stride length and stride length variability der cognitive-motor dual-task condition in older adults.
under the single-task condition and stride length vari- Indeed, dual-task gait performance improved in the music- ability under the dual-task condition, as well as in 1-legged based multitask exercise program group, with reduc- stance duration and Tinetti test performance.
tion in stride length variability, regardless of gait veloc- Between 6 and 12 months, 56 participants in each ity modification. All statistical analyses showed similar group were followed up for falls. Sixteen subjects (29%) results, which confirm the robustness of our findings. Few in the early intervention group had at least 1 fall and 4 studies to date have demonstrated an improvement of (7%) had fallen repeatedly, with 20 reported falls. The dual-task gait performance with training, including stud- incidence of falls, proportion of subjects with 1 or more ies in patients with stroke, Parkinson disease, or demen- falls and those with multiple falls in this group did not tia or in older adults, but most of their sample sizes were differ between the intervention and the follow-up pe- small.43-47 Our study also indicates that gait variability may riod (P=.63, P=.64, and P=.71, respectively). During the be improved under a single-task condition, as was pre- 2010 American Medical Association. All rights reserved.
Table 3. Change in Balance and Functional Outcomes
Mean (SD)
Mean (SD)
Baseline
Changes at 6 moa
Adjusted
Changes at 12 mob
Effect,d
Between-Group
P Value
Intervention Intervention Intervention Intervention
Difference
P
Intervention Intervention
Outcomes
Sequence vention
Abbreviations: CI, confidence interval; A-P, body sway in anteroposterior direction; M-L, body sway in mediolateral direction.
a Changes were calculated as 6-month follow-up minus baseline.
b Changes were calculated as 12-month follow-up minus 6-month follow-up.
c Analyses of covariance on change in measures with the baseline value as covariate.
d Crossover analysis of variance on change in measures using a specific procedure dealing with the analysis of crossover experiments, which provides significance values for respectively sequence, period, intervention, and carryover effects. Ellipses represent nonsignificant values.
viously suggested in older adults, in particular after train-ing or pharmacological interventions.48-52 The same find- ing was also recently reported in healthy older adults after We can only speculate on the factors responsible for the detected improvements in dual-task gait variability: they could be related to more automated tasks, to task coordination skills development, or to both.46,54 The in- tervention effect under other dual-task conditions (eg,motor interference tasks) needs to be further explored.
Also, the intervention may involve increased gait per-formance by improving attention and executive func- Figure 2. Stride length variability under the dual-task condition for both
tion.55-58 An association between gait variability and ex- groups. Values represent means using last observation carried forward.
ecutive function, particularly during dual tasking, has been Error bars represent 95% confidence intervals.
reported in elderly fallers (those with Ն1 fall).59 Fur-ther work is needed to fully assess the impact of this pro- plication for older adults, since a low gait speed was found gram on cognitive performances, using a comprehen- to be a consistent risk factor for disability, institutional- sive neuropsychological battery for executive functions.
ization, and mortality.61 An increase in self-confidence The current findings extend the existing knowledge may explain these findings.62 An improvement of bal- of the efficacy of physical exercise interventions to im- ance in 1-legged stance is also consistent with previous prove gait, balance, and functional capacity in elderly reports of improved 1-legged stance time following a wide people.8,60 The improvement observed in gait velocity is range of exercise programs.63 These changes were also consistent with a meta-analysis that reported a success accompanied by small but significant gains in func- rate of 57% after exercise training to improve usual gait tional performances. Modifications in the Tinetti score speed.60 This finding may have an important practical im- after the intervention were mainly due to an improve- 2010 American Medical Association. All rights reserved.
Table 4. Falls at the 6-Month Follow-up
Intervention
Intervention
Outcomes
Unadjusted
Adjusteda
Participants with multiple (Ն2) falls, No. (%) Abbreviations: CI, confidence interval; HR, hazard ratio; IRR, incidence rate ratio; RR, relative risk.
a Adjusted for age, history of falls over the previous 12 months, simplified Tinetti test performance, and total number of frailty criteria (accordingtoFried et al21) ment in the performance of the 1-legged stance task. Un- may have resulted in reporting bias. Second, the results expectedly, there were no differences in sway para- should be interpreted in light of the eligibility criteria and meters in the 2-legged stance task and the dynamic task with regard to the gender imbalance in the study popu- of sitting to standing. The latter task mainly requires lation. The overwhelming predominance of women re- greater lower extremity strength, which was only a small cruited may be partly explained by demographic factors (ie, in Switzerland, women 65 years and older outnum- Although the study was not powered to detect between- ber men by approximately 1.35 to 1) and movement to group differences in falls, a reduction in the incidence music activities being more attractive for women. In ad- of falls, and in the risk of falling was found. While com- dition, the participants who enrolled in this trial prob- parisons between trials are difficult when there are dif- ably had a greater interest in health issues than the gen- ferences in study design, core components of the inter- eral population of elderly people. This might have resulted ventions, population targeted, intervention duration, or in the inadvertent selection of more motivated individu- assessments of falls, the 54% reduction in falls observed als. Third, there was no attention control group. Fourth, in our study compares favorably with the rates observed the number of withdrawals could be a limitation, but it in the most effective exercise-based interventions re- was taken into account in the power calculation. Fi- ported so far, with a meta-analysis demonstrating an over- nally, there was only 1 class instructor and the out- all fall reduction of 37% for Tai Chi interventions.7,8 Our comes achieved took place at 1 center. Therefore, fur- results are in agreement with another meta-analysis, which ther studies are needed to confirm the generalization showed that interventions involving a large balance com- ponent are the most effective for preventing falls among In conclusion, this randomized controlled trial is the older people.8 The fall risk reduction in our trial may have first, to our knowledge, to show that participation in mu- been related to the multimodal nature of the interven- sic-based multitask exercise classes once a week over a tion and to improvements in major risk factors for falls, 6-month period can improve gait performance under single and cognitive-motor, dual-task conditions, as well Jaques-Dalcroze eurhythmics seems to be able to change as improve balance, and reduce both the rate of falls and patterns of physical activity in elderly people by provid- the risk of falling in at-risk elderly community-dwelling ing a strong motivation for the initiation and mainte- adults. Our findings suggest that this program may be nance of exercise behavior, especially in women (96% of useful for fall prevention and rehabilitation in community- the participants in this trial) who are often less physically based settings such as senior centers.
active than men.65,66 The adherence to the intervention pro-gram was high (78%), compared with the mean rate of 63% Accepted for Publication: September 17, 2010.
reported in a review that examined exercise adherence in Published Online: November 22, 2010. doi:10.1001
elderly people,67 possibly in relation to the music compo- nent, which has been shown to facilitate exercise adher- Correspondence: Andrea Trombetti, MD, Division of
ence in older adults.68 Fifty-six percent of participants have Bone Diseases, Department of Rehabilitation and Geri- registered in new fee paying sessions after the study.
atrics, University Hospitals and Faculty of Medicine of Our study had some limitations. First, the nature of Geneva, 1211 Geneva 14, Switzerland (Andrea.Trombetti the intervention precluded blinding participants, which 2010 American Medical Association. All rights reserved.
Author Contributions: Dr Trombetti had full access to
fective exercise for the prevention of falls: a systematic review and meta-analysis.
the data in the study and takes responsibility for the in- J Am Geriatr Soc. 2008;56(12):2234-2243.
9. Berg WP, Alessio HM, Mills EM, Tong C. Circumstances and consequences of tegrity of the data and the accuracy of the data analysis.
falls in independent community-dwelling older adults. Age Ageing. 1997;26 Author Contributions: Dr Trombetti had full access to
the data in the study and takes responsibility for the in- 10. Niino N, Tsuzuku S, Ando F, Shimokata H. Frequencies and circumstances of tegrity of the data and the accuracy of the data analysis.
falls in the National Institute for Longevity Sciences, Longitudinal Study of Ag- Study concept and design: Trombetti, Hermann, Kressig, ing (NILS-LSA). J Epidemiol. 2000;10(1)(suppl):S90-S94.
11. Bloem BR, Valkenburg VV, Slabbekoorn M, Willemsen MD. The Multiple Tasks Ferrari, and Rizzoli. Acquisition of data: Trombetti and Test: development and normal strategies. Gait Posture. 2001;14(3):191-202.
Hars. Analysis and interpretation of data: Trombetti, Hars, 12. Bergland A, Pettersen AM, Laake K. Falls reported among elderly Norwegians Hermann, Kressig, Ferrari, and Rizzoli. Drafting of the living at home. Physiother Res Int. 1998;3(3):164-174.
manuscript: Trombetti and Hars. Critical revision of the 13. Maki BE. Gait changes in older adults: predictors of falls or indicators of fear.
manuscript for important intellectual content: Hermann, J Am Geriatr Soc. 1997;45(3):313-320.
14. Hausdorff JM. Gait variability: methods, modeling and meaning. J Neuroeng Rehabil.
Kressig, Ferrari, and Rizzoli. Statistical analysis: Trom- 2005;2(1):19. doi:10.1186/1743-0003-2-19.
betti, Hars, and Hermann. Administrative, technical, and 15. Priest AW, Salamon KB, Hollman JH. Age-related differences in dual task walk- material support: Hermann and Kressig. Study supervi- ing: a cross sectional study [published online November 14, 2008]. J Neuroeng sion: Trombetti, Ferrari, and Rizzoli.
Rehabil. 2008;5:29. doi:10.1186/1743-0003-5-29.
16. Brach JS, Studenski SA, Perera S, VanSwearingen JM, Newman AB. Gait vari- Financial Disclosure: None reported.
ability and the risk of incident mobility disability in community-dwelling older Funding/Support: This study was funded by the follow-
adults. J Gerontol A Biol Sci Med Sci. 2007;62(9):983-988.
ing organizations and foundations: Loterie Romande 17. Verghese J, Holtzer R, Lipton RB, Wang C. Quantitative gait markers and incident Geneva, Carigest SA, Gertrude Hirzel Foundation, Leena- fall risk in older adults. J Gerontol A Biol Sci Med Sci. 2009;64(8):896-901.
ards Foundation, Oltramare Foundation, Eagle Founda- 18. Jaques-Dalcroze E´. Rhythm, Music & Education. Rev ed. London, England: Dal- tion, Foundation for Geneva (Georges Junod Fund), Delta 19. Kressig RW, Allali G, Beauchet O. Long-term practice of Jaques-Dalcroze eurhyth- mics prevents age-related increase of gait variability under a dual task. J Am Geri- Role of the Sponsors: The funding sources had no role in
the design and conduct of the study; in the collection, man- 20. Tinetti ME. Performance-oriented assessment of mobility problems in elderly agement, analysis, and interpretation of the data; or in the patients. J Am Geriatr Soc. 1986;34(2):119-126.
21. Fried LP, Tangen CM, Walston J, et al; Cardiovascular Health Study Collabora- preparation, review, or approval of the manuscript.
tive Research Group. Frailty in older adults: evidence for a phenotype. J Geron- Additional Contributions: We thank the staff of the
tol A Biol Sci Med Sci. 2001;56(3):M146-M156.
Jaques-Dalcroze Institute of Geneva for their contribu- 22. Wahli-Delbos M. La Rythmique Jaques-Dalcroze, un atout pour les seniors. Geneva, tion, input and support. We are grateful to other mem- Switzerland: Editions Papillon; 2010.
bers of the project team for their invaluable assistance 23. Guigoz Y. The Mini Nutritional Assessment (MNA) review of the literature— what does it tell us? J Nutr Health Aging. 2006;10(6):466-487.
with this trial and to all the participants. Olivier Beauchet, 24. Richardson MT, Leon AS, Jacobs DR Jr, Ainsworth BE, Serfass R. Comprehensive MD, PhD (University Hospital of Angers, France), and evaluation of the Minnesota Leisure Time Physical Activity Questionnaire. J Clin Ste´phane Armand, PhD (University Hospitals of Geneva, Epidemiol. 1994;47(3):271-281.
Switzerland), revised the study protocol; Anne Winkel- 25. Manos PJ, Wu R. The ten point clock test: a quick screen and grading method mann assisted in project coordination; and Ruth Gian- for cognitive impairment in medical and surgical patients. Int J Psychiatry Med.
1994;24(3):229-244.
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