Overview

Daily life involves the successful completion of dual task walking activities and is a dynamic integration of motor and cognitive skills to meet environmental and postural demands to avoid a fall. Older Veterans face greater cognitive decline risk, greater comorbidities, and poorer health than non-veterans and have a higher age-related fall risk. Non-immersive VR motor-cognitive treadmill (VR-TM) training can improve balance, walking, and fall risk in older adults but has not been studied in older Veterans and has been largely studied in neurological populations. This pilot study proposed to investigate the acceptance and feasibility of using VR-TM among older Veterans with a history of falls or documented fall risk.

Subjects and Methodology:

Thirty community-dwelling older Veterans aged 65-to-88 years (26 male, 4 female) consented and twenty-three completed this single-arm pilot study. Participants received 14 treatment sessions over 7-weeks using a VR-TM system to walk over virtual obstacles on a treadmill. Balance performance, walking endurance, quality of life (QOL), fear of falling and balance confidence were assessed pre- and post-training. A satisfaction survey was conducted post-training. Descriptive statistics examined fall incidence prior to training and over a six-month retention. Paired t-test and Wilcoxon signed-ranked test performed on the twenty-three completers examined longitudinal change at significance level P = 0.05.

This was a single-arm prospective pilot study. Due to its pilot nature, there was no randomization, and all participants received the same VR-TM training  twice a week to complete 14 visits. Outcome measures were conducted pre- and post-training by an experienced assessor who was unblinded to the study training and was involved in the intervention. Fall incidence data was collected retrospectively prior to training, and prospectively during training sessions and over a six-month retention period. The study was approved by the University of Maryland Baltimore Institutional Review Board (IRB) and the Baltimore Veterans Affairs Research and Development Committee and study procedures were conducted in compliance with all ethical practices and guidelines.  

Results: 

The Mini Balance Evaluation Systems Test (Mini-BESTest) had a statistically significant change (20.9 ± 4.20; 23.13 ± 3.03; P = 0.01) and six participants had a 4-point improvement reflective of a minimal clinically important difference (MCID). The Activities-specific Balance Confidence scale improved post-training (65.18 ± 21.68; 73.04 ± 18.40; P = 0.02) and four participants had a > 18% (MCID) confidence gain. VR-TM training was a feasible intervention in this population and twenty-three out of the thirty consented Veterans (76.6%) completed the protocol. Ninety-four percent of these completers would recommend the VR-TM training to a friend.