MR 32832

Specificity of Exercise on Enhancing Cognitive Abilities:
Argentine Tango and Walking
Allison Jacobson, B.Sc. (Psychology)

School of Physical and Occupational Therapy
McGiII University, Montreal
February, 2007
A thesis submiUed to McGiII University in complete fulfillment of the

requirements of the degree of a Master's of Science
in Rehabilitation Science.
© Allison Jacobson, 2006

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ABSTRACT
The objective of this feasibility study was to determine for the elderly at-
risk for falls the eftects of a 10-week program in Argentine Tango dancing
or Walking on cognition. Thirty healthy community dwelling seniors (60+)
were recruited to take part in the study. They were evaluated at baseline,
post-intervention and follow-up on divided attention (Walking-While-
Talking) and working memory tasks. It was found that Tango dancing
significantly improved divided attention capabilities while the Walk
program significantly improved working memory. These findings need to
be replicated with a larger number of subjects.

ABRÉGÉ
L'objectif de cette étude de faisabilité était de déterminer les effets d'un
programme de 10 semaines de Tango argentin ou de marche sur les
fonctions cognitives de personnes âgées à risque de chutes. Trente
personnes âgées en bonne santé et de la communauté étaient recrutées
pour assister à l'étude. Ils étaient évalués au niveau de référence, post-
intervention et suivi sur des tâches d'attention partagée (parler en même
temps que marcher) et de la mémoire de travail. L'étude a trouvé que la
danse Tango a significativement amélioré les capacités d'attention
partagée alors que le programme de marche a significativement amélioré
la mémoire de travail. Ces résultats doivent être répliqués en utilisant un
plus grand nombre de participants.
11
ACKNOWLEDGEMENTS
A simple email about a summer research position was the starting point of
the journey that blossomed into my Master's thesis as weil as a wonderful
learning experience. 1 feel fortunate to have been involved in this unique
feasibility study.
First and foremost, 1 wou Id like to thank my supervisor, Dr. Patricia
McKinley, who has been there for me every step of the way, encouraging,
supporting and guiding me. Her comments and feedback played an
invaluable role in the progression of my thesis and 1 am truly grateful for
her time and patience. 1 consider myself lucky to have had the chance to
work with someone with such a passion for and wealth of expertise related
to scientific research. On a more personal note, Dr. McKinley's continued
belief and confidence in my various endeavours outside of the realm of my
thesis have meant the world to me, especially in my pursuit of a clinical
degree in Physiotherapy.
1 would also like to acknowledge the members of my Thesis Supervisory
committee, Dr. Constant Rainville and Dr. Lucinda Hughey for their
feedback and helpful input through out the various stages of my thesis.
During my Master's degree, 1 was fortunate to receive several different
sources of funding for research and conference attendance. 1would like to
thank the Social Sciences and Humanities Research Council of Canada
111
for the generous scholarship 1 was granted in the second year of my
Master's degree. 1 was also received funding from the School of Physical
and Occupational Therapy of McGiII University in the form of a travel grant
to attend the annual meeting of the Society for Neuroscience, where the
abstract for my project was selected as one of six presented at the
Society's press conference in Washington, D.C in November 2005. Grants
received for this project also enabled me to present a poster at the first
International Congress Gait & Mental Function in Madrid, Spain in
February 2006. The Tango project was also supported by a grant from the
Drummond Foundation.
Thank vou to the participants for volunteering to be part of this adventure.
Special thanks to Lucie Bouvrette, Victoria Bednarczyk Sheila Schneiberg,
and Mélanie Betournay for helping with the collection of the data. To Dr.
Julie Lamoureux and Eve-Marie Quintin, your knowledge in statistics and
willingness to answer ail of my questions was indispensable.
Last but certainly not least, 1 am very grateful for my family and friends'
support, without which 1 would not be where 1 am today. A very special
thank vou to my parents for always being there for me no matter what, for
their patience and encouragement.
IV
TABLE OF CONTENTS
ABSTRACT
ABRÉGÉ ii
ACKNOWLEDGEMENTS iii
TABLE OF CONTENTS v
LIST OF TABLES viii
LIST OF FIGURES ix
1. INTRODUCTION 1
2. REVIEW OF THE L1TERATURE 6
2.1 SENIORS: AT-RISK FOR FALLS 7
2.2 ROLE OF COGNITION 9
2.3 CONSEQUENCES OF FALLING FOR SENIORS 12
2.4 EXERCISE AND FALL PREVENTION 13
2.5 DIVIDED ATTENTION, AGING, AND FALL RISK 15
2.5.1 Definition of Divided Attention 15
2.5.2 Attention and Aging 15
2.5.3 Attention and Balance 17
2.6 WORKING MEMORY, AGING,
AND ACTIVITIES OF DAILY LIVING 19
2.6.1 Definition of Working Memory 19
2.6.2 Components of Working Memory Model 19
2.6.3 Phonological Loop 20
2.6.4 Visuo-Spatial Sketchpad 22
2.6.5 Central Executive 23
2.6.6 Episodic Buffer 24
2.6.7 Working Memory and Activities of Daily Living 26
2.7 HOW EXERCISE MAY ENHANCE COGNITION 27
2.8 SPECIFICITY OF EXERCISE 31
2.9 SIGNIFICANCE 33
v
2.10 RATIONALE 34
2.11 OBJECTIVES 34
2.11.1 Specifie Objectives 34
2.11.2 Hypothesis 35
2.12 RESEARCH QUESTIONS 35
3. METHODOLOGY 38
3.1 DESIGN 38
3.2 STUDY POPULATION 38
3.3 INTERVENTION PROGRAMS 41
3.4 MEASUREMENT INSTRUMENTS 43
3.4.1 Screening Toois 43
3.4.2 Outcome Measures 43
3.5 DATA COLLECTION 48
3.6 STATISTICAL ANALYSIS 49
3.7 ETHICS APPROVAL 49
4.RESULTS 51
4.1 DESCRIPTION OF SUBJECTS 51
4.2 WITHIN GROUP CHANGES 51
4.3 STATISTICAL ANALYSES 52
4.4 CLiNICAL ANALYSES 53
4.4.1 Divided Attention 53
4.4.2 Working Memory 55
4.5 COMPARISON BETWEEN GROUPS 57
4.6 EFFECT SIZES 57
4.7 BOX-AND-WHISKER PLOTS 58
5. DISCUSSION 79
5.1 DIVIDED ATTENTION 79
VI
5.2 WORKING MEMORY 84
5.3 SAMPLE SIZE 89
5.4 CLiNICAL IMPLICATIONS 90
5.5 CONCLUSIONS AND SUMMARY 94
5.5.1 Limitations 95
5.5.2 Future Directions 95
LIST OF REFERENCES 98
APPENDICES 112
APPENDIX 1: Recruitment Ad 113
APPENDIX 2: Ethical Approval 114
APPENDIX 3: Informed Consent Form 116
APPENDIX 4: Social Scales 122
Vll
LIST OF TABLES
SECTION 4
Table 1: Baseline Measures 61
Table 2: Within Group Changes 62
Table 3: Analysis of variance for the Two Interventions 64
Table 4: Effect Sizes 65
V111
LIST OF FIGURES
SECTION 1
Figure 1. Relationship between physical activity and fall risk
in the elderly 5
SECTION 2
Figure 2. Working Memory Model 36
Figure 3. McAuley, Colcombe and Kramer's 2004 model 37
SECTION 3
Figure 4. Flow chart of the study 50
SECTION 4
Figure 5. Divided Attention Performance 66
Figure 6. Auditory Memory 67
Figure 7. Working Memory 68
Figure 8. Spatial Memory 69
Figure 9 (a). Divided Attention: Tango Group 70
Figure 9 (b). Divided Attention: Walk Group 71
Figure 10. Working Memory 72
Figure 11. Changes in Working Memory Score 73
Figure 12. Box-and-whiskers Plots: WWT 75
Figure 13. Box-and-whiskers Plots: Letter-Number Sequencing 76
Figure 14. Box-and-whiskers Plots: Spatial Span 77
Figure 15. Box-and-whiskers Plots: Working Memory 78
Figure 16. Changes in Working Memory without the two outliers 96
IX
1. INTRODUCTION
The Canadian society is growing older each year as the number of
seniors living is increasing at a higher rate than their younger
counterparts. To keep older adults physically and mentally healthy, it is
imperative that they stay active and fit. A healthy lifestyle centered on
physical activity helps to maintain seniors' quality of life and
independence, as their health is intricately related to their independence.
The infamous "use it, or lose it" theory applies directly to older adults
because if seniors do not stimulate their cognitive and physical faculties,
they will experience measurable decline in these abilities. However,
despite government initiated programs to raise awareness about being
active and pro-exercising advertising campaigns, approximately 60% of
older adults in Canada are physically inactive (Statistics Canada, 2006).
Low levels of physical activity reduce seniors' aerobic capacity and
strength, thereby lowering their functional independence and augmenting
disuse atrophy of their muscles, consequently elevating fall risk. This
relationship positively feeds back on the amount of exercise older adults
engage in, resulting in a vicious cycle of decreasing levels of physical
activity and escalating risk for falls (Figure 1).
There is a great need for an exercise program to be implemented in
the community setting that is both sustainable and motivating for seniors.
1
Integrating a social component within the exercise intervention is also
necessary as many older adults live alone and spend between 5 to 10
hours a day without any human contact (Statistics Canada, 2002). The
Argentine Tango was chosen as such a leisure-based exercise program
for numerous reasons. The Tango is improvisational and the dancers need
to be creative as they dance, combining the steps they have learned while
keeping in time and pace with the music. Both the leader and the follower
must communicate with one another, their cues are signaled either by the
pressure on the follower's back, leader's chest or upper arm in order to
flow across the dance floor.
Tango is particularly challenging as an intellectual and postural
exercise; to avoid other couples and maintain an overall counterclockwise
progression, partners must navigate in the immediate space while
anticipating where they will be moving, and, at the sa me time, respond to
each other to perform the dance components in an improvised manner.
They have to anticipate what others will be doing in the dance space,
execute their own step sequence without bumping into another couple,
and maintain independent postural control. This situation makes it difficult
to predict in advance the sequence of movements to be performed. As
partners are encouraged to exchange roles during the learning of Tango
steps, both partners will gain experience in being the leader and follower,
2
eliminating the need to have equal numbers of men and women. In
addition, Tango instruction also focuses on individual practice far the dual
purpose of learning steps and far practicing balance maintenance, as it is
critical that each partner maintain stability and balance without leaning on
the other partner. These two elements of constant unpredictability and
postural alignment are unique to the Argentine Tango instruction as other
ballroom dancing classes focus on set combinations of steps or very
routine steps that are repetitive. Une dancing is even more stereotypie
and although it is social in nature, it does not require interaction between
partners. In short, Tango is unpredictable because of the inter and intra
partner interactions and the progression in the line of dance of everyone
on the floar; it therefore has an increased cognitive load related to
navigation in space, and rotation and can serve to focus attention on
maintenance of balance when experiencing multidirectional perturbations.
As weil, dancing is a fun, social activity that is in stark contrast to many of
the exercise programs currently available in the community which are
individually-based and introspective activities such as Tai Chi, yoga or
gym circuit training. Furthermore, as a physical activity, Tango targets
three important elements that are crucial for seniors to lead a healthy and
active lifestyle: balance and mobility, cognitive skills and the promotion of
social integration. Since the Tango generates specifie, aUainable goals,
3
such a program would incorporate social support and self-efficacy factors
that would entice aider adults ta be motivated and continue exercising.
Sustainability of these types of activities for this population is critical in
prevention of isolation, physical decline and quality of life. It is of utmost
importance that we promote physical activity which is also cognitively
stimulating that will engage aider adults and motivate seniors ta keep
active.
4
Figure 1. Relationship between physical activity and fall risk in the elderly
low levels of physical activity

~~ _ _ _ _ _ _~_ _ _ _ _ _- J
l Ed physical fitness
l functional independence
disuse atrophy
- t ed risk for falls
Illustration of the relationship between low levels of physical activity in the

elderly which leads to increased risk for falls.
5
2. REVIEW OF THE LlTERATURE
The elderly population is rapidly growing in Canada. According to
the Annual Demographie Statistics, the total number of seniors (aged 65+)
was approximately 5.7 million persons in 2005 (Statistics Canada, 2006).
Seniors account for 17.8% of the total Canadian population, a percentage
that has been steadily rising since 1981 and is expected to reach 22.6%
by the year 2041 (Colin, 1999). The growing trend of older adults living in
Canada in turn leads to an increased work load for medical and
rehabilitation professionals, as the elderly are more likely to be
hospitalized than any other age group (Statistics Canada, 2006). Once
they are hospitalized, the length of stay of older adults (65+) is much
longer than that of younger individuals (>65), an average of 17 days
compared to averages between 3 to 8 days respectively (Colin, 1999).
This increased use of the health care system entails greater costs due to
hospital stays and procedures, treatment, medication, and home and
residence care. Extended periods in hospitals result in more time spent on
6
bed rest, further exacerbating the associated risks of aging: osteoporosis,
incontinence, deconditioning, and diminished functionality and mobility
(Gill, Allore, & Guo, 2004). Among the elderly population, 38.6% of
individuals aged 65-84 and 75.2% of people aged 85 and up have
functional disabilities (Hogan, Elby, & Fung, 1999). Consequently, ways
need to be found to reduce hospital stays and long periods of bed rest in
this population.
2.1 SENIORS: AT-RISK FOR FALLS
ln the elderly population, the reason for 10% of trips to the
emergency room and 6% of urgent hospitalizations is a fall (Tinetti, 2003).
Fall risk escalates as people age; approximately 1/3 of community
dwelling older adults experience at least one fall per year, and this rate of
falling increases by 10% for the population over 85 years of age (Tinetti,
Speechley, & Ginter, 1988). As weil, the first fall experienced by an older
individual puts this person at risk for subsequent falls. If a person falls and
sustains an injury, these injured fallers are 3 times more likely to use
7
hospital services and 16 times more likely to be placed into a nursing care
facility than nonfallers (Rizzo et aL, 1998). Concomitantly, there is a
monotonie increase in hospital utilization costs associated with the seve rit y
of falls. The current cost in terms of health care and associated expenses
is already large, as approximately 1 billion dollars is spent on treatment for
seniors who have fallen (National Advisory Council on Aging, 1999).
These costs will continue to grow as the baby boomer generation ages
unless con crete programs are developed to decrease fall risk in this
population. In fact, the annual co st of hospital fees for fallers who
experienced an injury from a single fall is $988 more than for nonfallers,
the total overall cost coming to an additional $2,500. The cost rises even
more dramatically (Rizzo et aL, 1998) as the number of falls experienced
increases (2 falls, additional $4,175/year, total $11,900 more than
nonfallers). SMARTRISK (1998) estimated that a reduction of twenty
percent in falls by seniors would result in a savings of 138 million every
8
year, as it would decrease the number of hospitalizations and the number
of people becoming permanently disabled over the age of 65.
2.2 ROLE OF COGNITION
There are many weil documented risk factors for fa Ils. While they
include the obvious and publicized factors such as medication,
functionality problems affecting the lower extremities, proprioception, low
body mass index, balance and gait abnormalities, one of the most
influential but lesser known risk factors is cognitive impairment (Alexander,
Ashton-Miller, Giordani, Guire, & Schultz, 2005; Tinetti, 2003; Tinetli et al.,
1988). The cognitive status of an individual is a critical issue as cognitive
processes are heavily involved in the regulation of ambulation and
movement in one's everyday life. In situations where an older person is
walking, the atlentional costs of walking decrease the amount of attention
that the person can allocate to a secondary task. Evidence of these
increased atlentional demands for the elderly while walking can be seen in
their increased reaction time to a secondary stimulus (Sparrow, Bradshaw,
9
Lamoureux, & Tirosh, 2002). Brown, Shumway-Cook and Woollacott
(1999) ascertained that the maintenance of one's posture requires and is
dependent on a person's attentional capacities. This study also
demonstrated that older adults necessitate greater attentional resources
than younger adults when trying to stay upright following a perturbation.
The competing demands on an older adult's attention may lead them to
experience a greater number of falls. Chen, Ashton Miller, Alexander, and
Schultz (1994) found that while walking, older adults have more difficulty
at avoiding obstacles than young adults. Older adults take significantly
longer to perceive an obstacle in their way; their chances of veering away
from an obstacle's path decreases if there is only a short amount of time to
notice it, for example, if the obstacle suddenly pops up. In a recent study
(Schrodt, Mercer, Giuliani, & Hartman, 2004), elderly subjects were able to
walk around an obstacle and accomplish a cognitive secondary task
simultaneously. However, the obstacle was present at the beginning of
testing and the participants were weil aware of it. As such, they were able
10
to prepare themselves in advance for the upcoming obstacle. Schrodt et
al. (2004) suggest that it is possible older adults have trouble avoiding
obstacles when their attention is divided and a time constraint is felt.
Schrodt et al. (2004) did observe that the older adults prioritized the
maintenance of their stability, gait and ability to avoid obstacles over the
secondary cognitive task. Shumway-Cook, Woollacott, Kerns, and
Baldwin's 1997 study demonstrated that by adding a cognitive task or
decreasing the stability of the surface that older adults are standing on,
older adults will have an increasingly hard time at maintaining their upright
posture. Therefore, when older adults try to stand upright while their
posture is being challenged, simple cognitive tasks can adversely affect
their ability to maintain their equilibrium. This type of situation is present in
everyday life, for example, crossing an icy street in the winter while talking
with a friend, or when carrying groceries. In environmental circumstances
which threaten posture and stability, older adults will choose maintaining
their posture their priority at the expense of accomplishing a secondary
11
task (Brown, Sieik, Polych, & Gage, 2002). This is because the elderly
perce ive the consequences of a fall to be severe.
2.3 CONSEQUENCES OF FALLING FOR SENIORS
The consequences of falls in the elderly are numerous. Falling can
result in sprains, strains, fractures and even death (King, & Tinetti, 1995).
Hip fractures, in particular, are extremely incapacitating for seniors. One
year following a hip fracture, 40% of seniors are not able to walk
independently, requiring a cane or walker to assist them while another
60% have difficulty performing essential activities of daily living, such as
getting dressed and/or going to the bathroom (Public Health Agency of
Canada, 2005). Twenty percent of the elderly are placed into long term
care facilities after breaking their hip as their spouse or family can no
longer care for them adequately. The mortality risk following hip fractures
is estimated to be between 11.5% and 15% (Parker, & Anand, 1991;
Richmond, Aharonoff, Zuvkerman, & Koval, 2003). Hip fractures and the
associated costs and consequences will continue to plague Canadian
12
society as its population ages. Furthermore, falling and the fear of
potential injuries greatly affect the confidence of elderly individuals which
can lead to restricted activity and social isolation. Seniors begin to avoid
leaving their homes for fear of hurting themselves. While being
homebound can result in further deconditioning, this lack of mobility also
leads to additional costs for social services for these house-bound seniors
and isolation, which can put them at risk for cognitive impairment. This
aspect is important as cognitive abilities play an instrumental role in
activities of daily living, particularly in the domains of divided attention and
working memory.
2.4 EXERCISE AND FALL PREVENTION
ln their examination of systematic reviews, Sherrington, Lord, and
Finch (2004) found mounting evidence that group exercise interventions
that target balance can reduce the incidence of falls among the elderly
living in the community. In addition, using exercise as a means of reducing
the risk for falls in older adults has been confirmed with several meta-
13
analyses (Chang et aL, 2004; Hill-Westmoreland, Soeken, & Spellbring;
Province et aL, 1995). A randomized clinical trial (Barnett, Smith, Lord,
Williams, & Baumand, 2003) reinforced the conclusions of the
aforementioned meta-analyses as the researchers found that a group
exercise program significantly reduced the rate of falls. Several studies
using Tai Chi as an exercise intervention for older adults have shown
improved postural (Tse, & Bailey, 1991), biomedical and psychosocial
parameters as weil as reducing fear of falling and rate of falls in seniors
(Wolf et aL, 1996). Tai Chi also positively effects physical functioning and
self efficacy for older adults (Li et aL, 2001). Improved flexibility, balance
and total body strength have resulted from walking and resistance training
program in the elderly (Simons, & Andel, 2006) while walking on a regular
basis has been shown to ameliorate postural control in seniors (Melzer,
Benjuya, & Kaplanski, 2003). These studies did not elaborate on the
mechanism responsible for the reduction in the number of falls in the
14
elderly, as their primary objective was to determine the efficacy of the
exercise program of preventing falls.
2.5 DIVIDED ATTENTION, AGING, AND FALL RISK
2.5.1 Definition of Oivided Attention
Signalling to change lanes while driving, or double checking a
recipe when stirring ingredients into a pot are just two examples of daily
situations that require individuals to divide their attention efficiently.
Oivided attention is the ability of being able to focus and complete different
tasks concurrently. Multi-tasking has become widespread in this era of
increasingly sophisticated technologies, and the ability to accomplish more
than one task simultaneously is of increasing importance for completion of
daily tasks.
2.5.2 Attention and Aging
While taken for granted in many situations, multi-tasking can be
demanding on the cognitive resources of an elderly person. This aspect
has been especially weil studied in driving using percentage of Useful
15
Field of Vision (UFOV) to measure divided attention capacity. In one
study (Ponds, Brouwer, & van Wolffelaar, 1988), it was found that ability to
divide attention weakens as one ages, as older subjects performed
significantly worse than young and middle-aged participants on a dual task
paradigm that simulated driving. A follow-up study (Brouwer, Waterink,
van Wolffelaar, & Rothengatter, 1991) concluded that the reason for the
poor divided attention ski Ils in older individuals was due to impaired
response integration abilities. Another driving study (Owsley et aL, 1988)
found that UFOV was a significant predictor for crash risk. Older adults
who drive with large reductions in the percentage of UFOV (40% or more)
were twice as likely to be involved in a car crash than older individuals
whose UFOV was less reduced. Deficits in the divided attention
component of the UFOV, in comparison to disabilities in selective attention
and speed of processing, demonstrated a statistically significant
augmented risk of being part of a car accident. Due to the cognitive
16
disadvantage suffered by the elderly, they must work even harder to
maintain divided attention.
2.5.3 Attention and Balance
More recently, interest has revolved araund the impact of divided
attention tasks and balance maintenance, as this ability may be critical for
reducing fall risk. For example, being able to avoid obstacles is
dependent on one's divided attention capacity, as it was shown that in
older adults, the percentage of UFOV (Braman el aL, 2004) is associated
with colliding with objects while walking. Poor divided attention and visual
processing ski Ils, represented by large reductions in the percentage of
UFOV, signified greater levels of bumping while walking. Owsley and
McGwin's study (2004) focused on the raie of visual attention in relation to
mobility in older adults. It was found that deficits in divided attention
contribute to the problems that the elderly experience with ambulation and
movement even after taking other covariates (such as age, sex and
cognitive status) into consideration. This finding has direct implications on
17
the design of geriatric interventions which need to target divided attention,
as this capability profoundly impacts older individuals' locomotion.
Verghese et al. (2002) ascertained that the time needed to complete a
divided attention task predicted falls in older individuals. Survival analysis
showed that this divided attention task was able to identify fallers and
nonfallers. Finally, Maki and colleagues (2001) have found that the elderly
are less able to switch their attentional resources from a cognitive task to a
balance threat than young adults, thereby negatively affecting their
stability. Examining attention in relation to balance using dual task
paradigms will help researchers and clinicians understand the effect of
aging on divided attention as weil as create better assessment and
evaluation tools for populations at risk for falls and for persons with
balance related problems (Woollacott & Shumway-Cook, 2002). Research
into incorporating dual task paradigms into rehabilitation programs for the
cognitively impaired geriatric population would be useful for ameliorating
their poor postural control (Hauer et aL, 2003).
18
2.6 WORKING MEMORY, AGING, AND ACTIVITIES OF DAILY LIVING
2.6.1 Definition of Working Memory
Working memory is the cognitive capacity that permits individuals to
reason and make sense of the world around them, from recalling what
needs to be bought at the grocery store to figuring out solutions to math
problems. It is the memory system that allows one to understand, retain
and integrate multiple facts and or thoughts (Baddeley, 1999). Baddeley
(1998) has proposed that working memory uses conscious awareness to
join ail the sensory information the brain receives into a cohesive unit
which is stored and can be recalled as needed. Complex thought
processes such as comprehension, reasoning, learning and problem-
solving are contingent upon working memory since this system is
presumed to have a fixed capacity. Processing problems arise when
working memory reaches its maximum capacity.
2.6.2 Components of Working Memory Model
19
Working memory was developed as a model to help comprehend
how human memory functions. It began as a merger of short-term and
long-term memory and has subsequently become more complex with
increasing research into the domain of working memory. Currently, the
most accepted model is that of Alan Baddeley and Graham Hitch
(Baddeley, 1986). Their multi-component model is made up of the
phonological loop, visuo-spatial sketchpad, the central executive (Figure
2a) and the recent addition of the episodic buffer (Figure 2b). The central
element of working memory is the central executive which is assisted by
the other subsystems. By funnelling off secondary and trivial tasks to its
slave systems, the central executive frees itself up for more pressing and
complex demands. The components of Baddeley and Hitch's intricate
working memory model are considered to be interdependent and there
can be some overlap in each separate part's function.
2.6.3 Phonological Loop
20
The phonologicalloop, one of the original components of Hitch and
Baddeley's 1974 working memory model, is a subordinate system
composed of an interim storage place and a rehearsal process. The
phonological loop is where auditory memories can be kept and made
permanent via the rehearsal mechanism. This mechanism is thought to be
a kind of "sub-vocal speech" (Baddeley, 1999, p. 170) whereby repeating
the new verbal stimuli in one's mind, a representation is stamped into
storage by articulatory rehearsal. The phonological loop is the most
studied constituent of the working memory model and is often the one at
fault in patients with short-term memory problems. The function of the
phonological loop is thought to be a reserve structure for comprehension
as weil as a method for acquiring language. The left temporoparietal
cortex has been identified as the anatomical location of the phonological
loop in les ion studies. The position of the storage component of the
phonological loop is situated in Broadmann Area (BA) 40 and the
rehearsal segment is located in Broca's area (BA 6/44) (Baddeley, 2003).
21
2.6.4 Visuo-Spatial Sketchpad
The second slave system of the 1974 working memory model is the
visuo-spatial sketchpad. The visuo-spatial sketchpad preserves temporary
traces of visu al and spatial information. Much less is known for certain
about this part of the model, it is hypothesized to be crucial in
remembering visual atlributes (colour, shape) and the idea of additional
sub-systems within the visuo-spatial sketchpad has been raised. The
capacity of the visuo-spatial sketchpad is approximately three to four
items. Neuroimaging studies have identified the right hemisphere in
association with visual working memory, in particular the right premotor
cortex (BA 6), the anterior extrastriate occipital cortex (BA 19), the right
inferior parietal cortex (BA 40) and the right inferior parietal cortex (BA 47)
(Baddeley, 2003).
1n the visual cortex, there are two major pathways for processing
information. The ventral stream which goes through the temporal lobe is
responsible for recognizing and retaining object information. This pathway
22
is also known as the "what" pathway. The other principal stream is the
parietal stream whose functions include spatial orientation and guiding
movement. The parietal pathway is also referred to as the ''where''
pathway (Baddeley, 2003; Undergleider & Mishkin, 1982). Spatial
memory is lateralized to the right hemisphere of the brain while verbal and
object memory is localized on the left (Smith & Jonides, 1997).
2.6.5 Central Executive
The attentional controller of the entire working memory system is
the central executive. Despite being the most important constituent of the
working memory model, there is the least amount of conclusive research
concerning the central executive. It is believed to have a fixed capacity
and is responsible for storing, organizing and synthesizing information.
Central executive integrates knowledge from its slave systems in order to
accomplish high level cognitive processes (for example, learning,
understanding and analyzing). The central executive is linked with
"midlateral prefrontal regions, particularly left and right dorsal lateral
23
prefrontal cortex" (Henson, 2001). Evidence from lesion and neuroimaging
investigations confirms that executive working memory tasks are found to
activate the prefrontal cortex, parietal cortex, cerebellum and striatum
(Bunge, Klingberg, Jacobsen, & Gabrieli, 2000).
2.6.6 Episodic Buffer
Several flaws of the original three-part working memory model have
emerged, compelling Baddeley to revisit and modify the theoretical
account of working memory. Sorne of the problems identified were that
there was no mechanism that could enable chunking 1 , no route to allow
the phonological and visuo-spatial components to communicate and no
means to account for working memory in conscious awareness (Baddeley,
2003). Thus, the fourth piece of the working memory model was
1 Chunking - Method of keeping a larger amount of units of information in short-term

memory than would otherwise be possible by organising related units into one collective.
This method is often used by chess players for remembering board positions and
mathematicians for cutting down the necessary steps for solving a problem. Studies by
Chase and Simon (1973) and Rosenbloom and Newell (1986) indicate that the larger the
understanding of relations between positions or rules, the larger the amount of units in a
chunk. http://www.psybox.com/webdictionary/Chunking.htm. Retrieved January 101h,
2006.
24
introduced, the episodic butter (Baddeley, 2000). The episodic butter
permits integration of knowledge from ail the other components of the
working memory model as weil as long-term memory because the
episodic butter operates in a universal code. The episodic butter is
transitory with a limited capacity size. It is accessible via consciousness
awareness but the episodic butter is run by the central executive. The
episodic butter allows for the binding of new pieces of information or
events together into an amalgamated, coherent unit that can be
remembered and retrieved. The fourth component of working memory
enables the brain to register new cognitive memories and representations,
thereby aiding in problem solving situations. Its precise whereabouts are
still unclear, however, findings from Prabhakaran et al.'s functional
magnetic resonance imaging study (2000) suggests that the general
location of the episodic buffer may be situated in the right frontal lobe as
there was an increase in activation in this area by integrated units of
verbal and spatial stimuli.
25
2.6.7 Working Memory and Activities of Daily Living
As with divided attention, most of the research in this area has
focused on the role of working memory in relation to driving, as it plays a
significant part in accomplishing this task weil. In particular, the visual
processing component is essential in order to accomplish the perception
and gross motor actions that are necessary while driving (Lundberg,
Hakamie-Blomqvist, Almkvist, & Johansson, 1998). More importantly, poor
cognitive skills are linked with car crashes and collisions. Poor visuospatial
memory, visuoconstructive ability and psychomotor speed have been
implicated in crashes while poor performance on memory tests,
specifically verbal and visuospatial ones, are features of elderly drivers
who had been part of car collisions but not of older adults who did not
experience them (Lundberg et aL, 1998). In a retrospective cohort study of
elderly drivers and car accidents, Lee, Lee, Cameron, and Li-Tsang (2003)
used logistic regression analysis to determine that there is a forty-five
percent reduction in risk of an accident associated for each additional
26
point on one's working memory score. Further investigation by Lee and
Lee (2005) led them to propose that driving interventions for older adults
should incorporate elements focusing on working memory. These findings
highlight the importance of being able to process information, manipulate,
and make appropriate judgments, critical abilities that one needs to be
capable of while navigating a car. As driving is closely linked with
independence for many seniors, particularly those living in rural
communities with poor public transport systems, maintenance of a
functional working memory as one ages is important. As decreased
independence reduces mobility and thereby increases fall risk, finding a
way to preserve working memory would be useful to the aging population.
Since there is liUle information directly related to working memory and
exercise, exercise may be a venue for maintaining and/or improving
working memory in seniors.
2.7 HOW EXERCISE MAY ENHANCE COGNITION
27
Among the healthy older population, there is a strong linear
relationship between physical and cognitive function (Rosano et al., 2005).
A longevity study (Schupf et aL, 2004) found that maintenance of cognitive
functions (memory, visuospatial, etc.) as weil as partaking in activities of
daily living were both predictors of living a longer life. The model proposed
by McAuley, Kramer and Colcombe (2004) depicts the biological
plausibility of using physical activity to promote cognitive functioning in the
elderly (Figure 3). This model is based on animal and human studies
which provide evidence that fitness and physical activity improves both
brain structures involved in both cognition and cognitive processes
themselves. Animal experiments have shown that physical activity resulted
in a variety of gains, such as greater number of synapses and capillaries
in the cerebellum of rats, and enhanced spatial learning and neurogenesis
in mice (van Praag, Kempermann, & Gage, 1999). Aerobic exercise has
multiple positive outcomes on the cognitive functioning of the aging
population, including reducing the neural degeneration associated with
growing older (Colcombe et aL, 2003). Using high resolution magnetic
resonance imaging, a high level of cardiovascular fitness in humans was
shown to protect gray matter (frontal, parietal and temporal lobes) and
white matter (anterior and transverse tracts), areas which are most
susceptible to age related declines (Colcombe et aL, 2003). Hall, Smith,
28
and Keele's (2001) review lends further support to the notion that aerobic
exercise produces positive improvements in executive function in the
elderly population. Aging is known to have severe detrimental effects on
executive functioning, which rely heavily on the brain's frontal lobes. Hall
et al. (2001) hypothesize that physical activity enhances executive
functioning by increasing blood flow to the frontal lobes. However, to date,
no study has truly investigated this hypothesis.
The FINE study (van Gelder, Tijhuis, Giampaoli, Nissinen, &
Kromhout, 2004) concluded that physical activity of medium-Iow intensity
or duration was associated with a smaller cognitive decline in older men.
Greater cognitive deterioration occurred if there was a decrease in the
duration or intensity of these individuals' physical activity, illustrating the
protective effects of exercise on cognition in the elderly. Rogers, Meyer,
and Mortel's 1990 longitudinal study examined the relationship between
health, cognition and level of activity in the elderly who have retired. In
comparison to retired-active and control working participants, retired-
inactive subjects scored significantly lower on a global cognitive
assessment test. Rogers et al. (1990) also examined regional cerebral
blood flow (CBF) which is a sensitive marker for progressive cerebral
atherosclerosis; CBF is known to decrease as one ages. The CBF levels
of inactive-retired seniors progressively decreased with each follow-up
29
year, whereas the levels of CBF for the other two groups of subjects
remained relatively stable over time. Rogers et al. (1990) concluded that
older adults who retire and become inactive "are at increased risk of
cerebrovascular disease and possibly cognitive impairments" (Rogers et
aL, 1990, p. 127). Results from a prospective cohort study by Laurin,
Verreault, Lindsay, MacPherson, and Rockwood (2001) found that the
likelihood of developing Alzheimer's disease and dementia is greatly
reduced with medium to high amounts of physical activity. This trend was
particularly strong in women and denoted "a significant dose-response
relationship" (Laurin et aL, 2001, p. 500), suggesting the more one is
physically active, the less likely that person is to become demented. Laurin
et al.'s findings are reinforced by another prospective study with
community-dwelling women (Yaffe, Barnes, Nevitt, Lui, & Convinsky,
2001). This study investigated whether there was a protective effect of
physical activity on the cognitive deterioration of older women. Yaffe et al.
(2001) ascertained that the risk of mental decline was reduced in women
who were more physically active at baseline as compared to those who
were more sedentary 6 to 8 years after. Pignatti, Rozzini, and Trabucchi
(2002) lend further strength to this line of thinking as their data replicated
the same results as Yaffe et al.'s 2001 study. Of the women who suffered
from cognitive decline, 16.7% had been classified in the high-Ievel of
30
activity group as compared to 39.5% in the low level activity group.
Pignatti et al. (2002) also established that there was an increased risk of
cognitive deterioration associated with low amounts of physical activity.
2.8 SPECIFICITY OF EXERCISE
While physiological responses to specific types of exercise are weil
documented, the specificity of exercise relating to cognitive functions has
only begun to be explored. Although there have been many studies
conducted in order to determine the positive effects of fitness on cognition,
the results have been mixed. Part of the reason for this discrepancy is due
to problematic methodology across studies such as a variety of different
exercises employed as the intervention, the age group targeted, the
cognitive measures examined and the type of comparison group.
However, a meta-analysis (Colcombe, & Kramer, 2003) demonstrated that
exercise enhances cognitive performance of executive, controlled, spatial
and speed tasks in the elderly population. The cognitive skill that had the
largest improvements due to physical activity was executive control
processes. It is possible that different types of exercise target particular
aspects of cognition and this idea needs to be taken into account while
designing a study.
An intervention geared towards increasing cognitive performance of
divided attention abilities requires selection of an activity which evokes a
31
multi-tasking experience. Recently, Verghese et al. (2003) found that in a
comparison of "playing tennis or golf, swimming, bicycling, dancing,
participating in group exercises, playing team games such as bowling,
walking for exercise, climbing more than two flights of stairs, doing
housework, and babysitting" (Verghese et aL, 2003, p.2510), the only form
of physical activity associated with a reduced risk of developing dementia
was dancing. However, they did not elaborate on the reasons for this
result. It cou Id be that dancing, more than the other activities evaluated,
exercises cognitive functions. On the other hand, it could be that various
aspects of cognitive function were enhanced with other activities, but
either were not measured, or were too subtle to be observed with the
study design. There is a paucity of literature related to dancing and its
possible beneficial effects on cognition for seniors. In order to assess the
role of physical activity in maintaining or enhancing cognitive function, we
have chosen to compare walking with dance, and specifically the
Argentine Tango. Both activities are of moderate intensity of three to six
metabolic equivalents (Physical Activity for Everyone: Measuring Physical
Activity Intensity, 2006). However, walking is a common activity of daily
living, while the Argentine Tango is a novel experience that truly captures
elements of divided attention due to the simultaneous need to pay
attention to the rhythm of the music, guide one's partner into the next
32
dance movement, or follow the eues of the leader. Furthermore, the
navigational demands of the Argentine Tango increase the complexity of
this activity as the dance requires the couple to maintain the flow around
the dance floor in a counterclockwise direction while manoeuvring around
the other couples on the dance floor. The primary objective of this thesis
will be to assess the cognitive benefits of both a Tango dancing program
and a Walk intervention in order to measure specifie changes in divided
attention or working memory that may be attributable to each specifie
program, and to discuss this with respect to specificity of exercise.
2.9 SIGNIFICANCE
The gains from such a program would not only include physical and
cognitive stimulation but would also target the specifie needs of elderly
populations such as divided attention, balance and motor coordination. An
improvement in these abilities could help lessen the fear of falling. In
addition, this program would promote a sense of community through the
formation of new partnerships and friendships. The socialization
component would increase exercise adherence and potentially reduce
social isolation. There are many biomechanical and psychosocial benefits
to this exercise program that would make it a great service for vulnerable
populations, such as the elderly, as weil as to the medical profession. It is
possible that the implementation of this kind of leisure therapy in a
33
community setting would help prevent the occurrence of fragility in seniors.
The co st of this intervention program is reasonable and can be put into
action easily at any community center, a friendly inviting atmosphere.
2.10 RATIONAlE
The links between exercise specificity and cognitive gains are not
clear in the literature. This study will help to explore this issue in greater
detail and help to determine the sam pie size necessary for a larger
randomized clinical trial.
2.11 OBJECTIVES
The objective of this feasibility study is to evaluate the efficacy of
Tango and Walk programs in the promotion of cognitive ski Ils.
1.11.1 Specifie Objectives
The specifie objectives are:
1. To determine if the cognitive function is increased after a Tango
dancing or Walk intervention program.
2. To determine if these improvements are maintained after the
cessation of the programs.
3. To establish the specifie cognitive gains associated with each
exercise intervention.
Two cognitive skills, divided attention and working memory, will be used to
evaluate each of three research objectives.
34
2.11.2 Hypothesis
The hypothesis is that type of exercise will be specifie to the aspects of
cognition it enhances.
2.12 RESEARCH QUESTIONS
1. After a 10 week program in Argentine Tango dancing or walking, is
there an increase in cognitive function?
2. Are observed changes maintained into the follow up period?
3. Does a 10 week exercise program in Tango result in different gains
in cognitive function from those in a Walk program?
35
Figure 2. Working Memory Model
(a)
Visuospatial Phonological
sketchpad loop
(b)
Visuospatial Episodic Phonological

sketchpad buffer loop
Adapted from Trends in Cognitive Sciences, pages 418 and 421, 2000.
(a) Diagram of the Working Memory model with the original three
components: phonological loop, visuo-spatial sketch pad and the central
executive.
(b) Diagram of the Working Memory model with the new addition of the
episodic buffer.
36
Figure 3. McAuley, Colcombe and Kramer's 2004 model
Environmental
Factors
(e,g" Available facilities.
Social support, Climate)
Disease Reduction
. (e.g, Cardiovascular
\ 1 Disease, Stroke, Diabetes,

Hypertension) \
1 Physical Activity -l> Rtness
Personal
Factors
\ Enhanœment in Brain
Structure and Function
/
Cognition
(e,g., Self·efficacy, SeW· (e.g, Increased production

schema, Exercise & efflciency of neurotransmitters,
history) Angiogenesis, Synaptogenesis,
Neurogenesis)
Adapted trom Brain, Behavior and Immunity, page 215,2004.
Model proposed by McAuley, Colcombe and Kramer (2004) demonstrating

how exercise may enhance cognition.
37
3. METHODOLOGY
3.1 DESIGN
This is a feasibility study that took place in the spring and summer
of 2004 from May to September. It was designed to explore the use of an
Argentine Tango dancing program as a means of exercise for the elderly
at-risk for falls and its effectiveness for improving cognition, balance and
mobility, and socialization. A Walk group was used for comparison.
Subjects were randomized into the two intervention groups.
3.2 STUDY POPULATION
Community-dwelling older individuals living on the Island of
Montreal were recruited to take part in this study through newspaper
advertisements as weil as flyers and posters in Centre Locaux De
Services Communautaires (CLSCs) and community centers. This strategy
wou Id reach different segments of the elderly population living in Montreal
and allow for the recruitment of many subjects within a short time period.
An example of the recruitment ad is in Appendix 1.
Inclusion criteria consisted of healthy individuals (60 years old and
up), to the extent that taking part in a Tango dancing or Walk program
would not exacerbate any existing symptomatology, who reported a fear of
falling, and had experienced a fall within the last year. A fall was defined
as 'events which lead to the conscious subject coming to rest inadvertently
38
on the ground' (Barnett et aL, 2003). This particular subgroup of the
elderly population is relevant to the interests of science as they are at a
higher risk for falling and the potential for improvement of divided attention
skills is great. In addition, the participants must be able to understand
written and spoken English or French.
Individuals with cognitive impairments (a score of less than twenty-
four on the Mini-Mental State Examination), progressive or unstable
neurological or musculoskeletal conditions were excluded to reduce the
confounding effects of these health states on the impact of the
interventions.
Individuals who responded to the advertisements were given a
preliminary screening to determine if they had fallen within the past year,
were afraid of falling, and were available for the entire length of the study.
Those individuals who appeared to fit the general criteria were asked if
they would accept to be interviewed over the telephone by a
physiotherapist to answer some questions related to their health status. 40
subjects were further screened with the interRAI, a telephone interview, by
a licensed physiotherapist. The interRAI is a validated and standardized
assessment instrument of physical and cognitive functioning in the
geriatric population (Challiner, Carpenter, Potter, & Maxwell, 2003).
Following the telephone interview, 34 potential subjects were invited to an
39
information session where the coordinators of the study explained in detail
the study protocol, the various testing procedures, and answered any
questions that the older adults had. As weil, the principal investigators re-
evaluated the individuals based on the inclusion and exclusion criteria and
then consent forms were distributed. 30 of the 34 seniors attending the
information meeting gave their informed consent to participate in the
study. Subjects went to the Constance-Lethbridge Rehabilitation Center
(CLRC) later that week for baseline evaluation. After completing the
baseline assessment, subjects were randomly allocated to the
experimental (Argentine Tango program) or control group (group Walk
Program) by selecting envelopes which contained group codes. Men were
stratified in order to have equal number of men in each group. Walking
was selected as a control activity as it is often used as such in exercise
physiology research (McAuley, Jerome, Marquez, Elavsky, & Blissmer,
2003), since it is a familiar activity of daily living which can be combined
with social interactions, when participating either with a partner or group.
Thus this activity was selected to compare how the specifies of each
exercise program might differentially target aspects of socialization,
cognition and mobility and balance, depending on the task demands and
concomitant group dynamics. The post program evaluation took place
following the termination of both interventions programs, and one month
40
later the follow-up evaluation occurred (Figure 4). The subjects who were
randomized to the control group were promised a 10 week Argentine
Tango course at the end of the feasibility study as an incentive to
complete the study and the Argentine Tango group was given the
opportunity to participate in either a Walk program or to continue with a
Tango course once a week.
3.3 INTERVENTION PROGRAMS
Both programs were given for 2 hours twice a week for 10 weeks,
for a total of 40 hours. 40 hours of instruction seems to be critical for
establishing gains with Tai Chi and other exercise programs in this
population (Wu, 2002).
The Argentine Tango program was led by a qualified Argentine
Tango instructor who had prior experience teaching older populations. The
classes were held in the gym at a local senior centre that contained a
mirrored wall and wooden floor. Atlendance was recorded by the Tango
instructor. The sessions followed a standard formula, starting with 30
minutes of warm up and single practice, 30 minutes of instruction and
practicing, a short break and 50 minutes of partner practicing. Single
practice was designed to rehearse weight shifting, proper postural
alignment and walking and pivoting, and practice of new and old dance
patterns while maintaining proper posture and balance. The couple
41
practice then reinforced the steps learned and rehearsed in the single
practice. The partner practice periods consisted of dancing in couples with
frequent switching of partners and changing of roles (leader or follower).
The dance steps progressed at a pace that was attainable by the
participants. Every week, the instructor incorporated new patterns of steps
into the sessions.
The group Walk program consisted of twice-weekly excursions to
various parks and locations in the greater Montreal area such as Mount
Royal, Ile de la Visitation and the Botanical Gardens. The seniors met as a
group at the Cummings Jewish Senior Centre and then went together in
taxis to the designated site. They returned to the centre for refreshments
at the end of the exercise period. The sessions were held outdoors,
unless the weather dictated otherwise, at which time they went to indoor
malis to walk. This happened approximately 3 times during the 10 weeks
of the Walk program. The majority of places that the Walk group visited on
their excursions were novel settings for the cohort, most of them never
having been to those areas before. Two guides who were graduates of the
Exercise Science program at a local University supervised, led and
coordinated the outings and served to counterbalance the effects of social
stimulation and attention of the Tango instructor.
42
3.4 MEASUREMENT INSTRUMENTS
3.4.1 Screening Toois
The interRAI Community Health Assessment instrument is a
reliable measure to determine the physical and cognitive functioning in the
elderly. It is short questionnaire that was developed to be used acrass
domains to ascertain whether older individuals require further evaluation
because their health or mental capacities are declining (interRAI, 2006).
The Mini-Mental State Examination (MMSE) was used as a
screening tool for cognitive status during the baseline (T1) assessment.
The MMSE is a valid and reliable test used to assess cognitive function
(Foistein, Foistein, & McHugh,· 1975). The MMSE is a simple,
standardized test that is reasonably fast to administer. Higher scores
reflect better cognitive status, the maximum score being 30.
3.4.2 Outcome Measures
For divided attention, the Walking-While-Talking (WWT) Complex
Task was selected as the measurement tool, as it is a quick clinical test
that assesses one's divided attention capacity in the performance of a
cognitive and manuallmobility task simultaneously. The subject must walk
fram a fixed starting point to an end point, turn and walk back while
reciting every other letter of the alphabet (a, c, e ... ) in French or English,
whichever was the most familiar or the mother tongue. During the course
43
of the WWT, the participant walks a distance of 20 feet, turns around and
walks back to the starting point for a total of 40 feet (12.19 meters). The
evaluator demonstrated the task once and the participant could ask
questions before performing the task to make sure that the task was
understood. The subjects were told to walk as quickly as possible while
reciting every other letter of the alphabet as accurately as possible. This
measure has been validated in the geriatric population and has high
interrater reliability (Verghese et aL, 2002). Verghese et al. (2002) also
found that the WWT-complex task had highest specificity and moderate
sensitivity in comparison to other commonly used measures that identify
older individuals at-risk for falls (Tinetti Balance and Mobility Scale and
Timed Gait). The WWT requires no expensive equipment, ma king it easy
to use. As weil, Chronister (2003) suggested that combining an
ambulatory task with a cognitive one would be a stronger predictor of falls
as this type of task would more accurately reflect the divided attention
situation individuals are faced with everyday.
There are several difterent measures which enable researchers to
evaluate the executive function of divided attention (Beauchet, Dubost,
Aminian, Gonthier, & Kressig, 2005). Other dual-task paradigms have also
used verbal cognitive tasks (Brown et aL, 1999; Shumway-Cook et aL,
1997) or a reaction time task (Brown et aL, 2002; Sparrow et aL, 2002) to
44
overload the subjects' attentional systems while attempting to maintain
balance following an unexpected perturbation. Reaction time tasks tend to
influence participants' gait characteristics as they need to focus on the
visual stimulus instead of their feet (Sparrow et aL, 2002) and are used to
examine the effects of ageing on attention. Verbal cognitive tasks are
generally employed to study the prioritization of balance versus
successfully accomplishing a cognitive task. Another executive function
measure used in the InCHIANTI study (Ble et aL, 2005) is the Trail Making
Test. This written cognitive test requires subjects to join together a series
of numbers in sequential order in the first part, and in the second section,
they must link numbers and letters together while alternating in numerical
and alphabetical order. The goal is to complete both parts as quickly and
as accurately as possible. A modified version of the Trail Making Test, the
Walking Trail Making Test (Alexander et aL, 2005), requires the
participants to accomplish the same tasks while walking instead of writing.
We selected the WWT as it is a clinically relevant method with established
metric properties for evaluating fall risk improvement and examines
divided attention in a typical activity of daily living that is known to place
seniors at risk for falls (Kwon, & Verghese, 2005;Verghese et aL, 2002).
45
Working Memory was measured by using the Wechsler Memory
Scale-III which is composed of two subtests, Letter-Number Sequencing
and Spatial Span. Each subtest examines a different aspect of working
memory. Together the results of each subtest are combined to give a total
score for Working Memory. The Wechsler Memory Scale-III is a reliable
and generalizable tool with content, criterion-related and construct validity
(Wechsler, 1997). The Wechsler Memory Scale-III is the standard
measure to evaluate memory function in clinical and research settings and
it is highly regarded for its ability to investigate age-related changes of
specifie memory processes.
Letter-Number Sequencing, the first subtest, examined the
subjects' auditory memory and capability to maintain and manipulate
verbal information concurrently. Letter-Number Sequencing is a short
standardized test with normative data for different age groups. The test
begins with the evaluator reading aloud to the participant a jumbled series
of letters and numbers. To formulate a correct answer, the subject must
remember ail the letters and numbers and reorganize them in his or her
response such that the numbers are stated first in ascending order,
followed by the letters in alphabetical order. Prior to starting the actual
test, the subject goes through a set of practice trials to familiarize
themselves with the testing procedure. For every level of the Letter-
46
Number Sequencing, there are three trials, each one having the sa me
quantity of stimuli but composed of different letters and numbers. As
Letter-Number Sequencing progresses, the string of letters and numbers
increases in length until the participant fails to achieve the proper order in
any of the three trials with a level and receives a score of O. The length
span of the sequences starts at two elements and proceeds to a maximum
of eight. The highest possible score one can achieve is 21. LeUer-Number
Sequencing is a reliable and valid test with good test-retest reliability
(Lemay, Bedard, Rouleau, & Tremblay, 2004).
Spatial memory was assessed using Spatial Span based on the
Corsi Block-Tapping task (Corsi, 1973). The Spatial Span task has been
utilized for both clinical evaluation and scientific research purposes to
measure spatial span and memory. The apparatus is a white plastic
square board (22 by 28 centimetres) with 10 blue blocks (3 by 3
centimetres) situated arbitrarily on it. The examiner taps a series of blocks
in a predetermined randomized order at a rate of one block per second.
Once the examiner has completed the demonstration of the sequence, the
subject may begin to reproduce the path under two different recall
conditions. The Forward Spatial Span task requires the subject to repeat
the sa me sequence of blocks as the examiner had, whereas in the
Backward Spatial Span, the participant must tap the blocks in the reverse
47
order that was demonstrated by the evaluator. Both conditions have high
interrater reliability (Wechsler, 1997). Similar to Letter-Number
Sequencing, the subjects went through several simulated trials in order to
become accustomed to the manner in which the Spatial Span is
conducted. There are two trials within one level of testing and as one
reaches the higher levels, the block span increases; beginning from two
blocks to the maximum of nine. As long as the subject successfully
recreates one out of the two sequences the examiner showed within a
level, the subject may continue on the following level of the Spatial Span.
Each of the recall conditions consist of eight levels, for a total of 16 points.
The maximum score on the Spatial Span subtest is 32 (Wechsler, 1997).
3.5 DATA COLLECTION
The week following the informational meeting with the study
coordinators and participants, at which the consent forms were signed, the
subjects had appointments at the CLRC for their baseline assessment.
Research assistants blind to group assignment conducted a series of
functional measures. The cognitive measures were performed byanother
research assistant who was also blinded to group assignment. These
preliminary tests served to establish baseline comparability between the
groups. The sa me sets of tests were repeated by the same evaluators
during the post-Tango/Walk and follow-up assessment periods. Both the
48
post-intervention and follow-up evaluation took place within a week of the
last intervention session and one month later, at week 11 and week 22
respectively.
3.6 STATISTICAL ANALYSIS
Statistical analyses were performed with GB-Stat version 9.0
software. Descriptive analyses of the two groups were calculated at
baseline pre-Tango/Walk on ail measures. Paired t-tests were conducted
in order to evaluate the within-group differences for the Tango and the
Walk groups (Question one and two). Between-group differences were
measured using 2 (intervention: Tango vs. Walk) x 3 (time: pre, post,
follow-up evaluation periods) way repeated measures ANOVAs and
examined graphically with box-and-whisker plots to analyze the variability
and distribution of the scores of each cohort.
3.7 ETHICS APPROVAL
The Conseil d'Éthique du Centre de Recherche Interdisciplinaire en
Réadaptation du Montréal Métropolitain (CRIR) approved this project
(Appendix 2). Prior to the commencement of the RCT, subjects had the
opportunity to ask questions in regards to the study and gave their written,
voluntary, informed consent at the informational meeting (Appendix 3).
Consent forms were available in bath English and French.
49
Figure 4. Flow chart of the study
Preliminary Screening
Telephone ca Ils to respondents
assessed by PT using the interRAI
n = 34
1
Introductory meeting
Signing of consent forms
n = 30
1
Assessment T1
Pre-Tango/Walk
1
Randomization by selecting
envelopes containing group codes
dropout
n=1
unrelated knee injury
l dropout
n=4
not receiving Tango
1 1
Tango Group Walk Group
n = 14 n = 11
1 1
Argentine Tango Group Group Walking Program
2 hours twice a week for 10 weeks 2 hours twice a week for 10 weeks
1 1
Evaluation T2 Evaluation T2
Post-Tango Post-Walk
1 1
Evaluation T3 Evaluation T3
Follow-up Follow-up
1 month later 1 month later
50
4. RESULTS
4.1 DESCRIPTION OF SUBJECTS
Thirty participants took part in the baseline evaluation, following
which five subjects dropped out of the study before the 10 weeks were
completed. Four were dissatisfied with the group allocation to the Walking
program and therefore withdrew, while one participant left the Tango
group because of an unrelated knee ailment. Twenty-five participants
completed the two interventions, with fourteen subjects in the Tango group
and eleven in the Walking group. Attendance in both programs was over
ninety percent. Ten subjects attended ail twenty sessions, twelve missed
one day and three were absent twice. As one subject from the Tango
program was unable to come in for the FUP evaluation, this subject was
removed from the data analysis, leaving thirteen subjects in the Tango
group. At baseline, the two groups were comparable in terms of age,
male-female ratio and score on the Mini Mental State Exam (Table 1).
Although there were no statistical difterences between the Tango and the
Walk groups at baseline for the outcome measures, there was a difterence
between the two cohorts in the spatial span score that approached
significance (p = .12), indicating that the conclusions drawn about Spatial
Span need to be treated with caution.
4.2 WITHIN GROUP CHANGES
51
Within group paired [-tests were used to statistically compare
baseline with post-intervention values to assess improvement and
between baseline and follow-up values to assess persistence of gains.
These results are presented in Table 2. Since statistical significance does
not always convey relevant improvement in task performance, we also
examined issues related to meaningful clinical outcomes. These topics
included the fall risk changes associated with the time required to execute
the divided attention task, as weil as working memory in comparison to
percentiles of normal age matched population and risk for driving
accidents. An improvement of one point represents a 45% decrease in the
risk of being a driver in a car accident for the elderly (Lee et aL, 2003),
which signifies a clinically important change.
4.3 STATISTICAL ANALYSES
For the Tango group, the WWT task for divided attention was
significantly improved from baseline at both post-intervention and at
follow-up, thus demonstrating a gain that persisted (Table 2). For the
Walk group, significant improvement was observed in the WWT at follow-
up, indicating that there might be a delayed effect, or that a longer period
of walking is necessary for improvement to emerge (Figure 5). By contrast,
the leUer-number sequencing (Figure 6) for the auditory memory
component of working memory and the summary score for working
52
memory (Figure 7) were significantly improved for the Walk but not the
Tango group at post-intervention. Only the working memory was
sustained into follow-up for the Walk group. Spatial memory was improved
at both post-intervention and follow-up for both groups, but these results
were not significant (Figure 8). Similarly, the Tango group showed
continued improvements in the letler-number sequencing task and working
memory throughout the study, although there was no significant
improvement at either post-intervention or at follow-up.
4.4 CLiNICAL ANALYSES
4.4.1 Divided Attention
There were also clinically meaningful changes in the divided
attention task performances of the individuals. In Figures 9 (a) and (b),
each individual's performance on the WWT over the three measurement
periods was plotted, using the high and low fall risk time demarcations as
proposed by Verghese et al. (2002). The changes in divided attention from
pre- to post-evaluation are examined in relation to performance time and
risk for falls. Individuals who finish the WWT task in 28.9 seconds or more
are at a higher risk for falls than those who are able to achieve the WWT
in 20.1 seconds or less (Verghese et al., 2002); these boundaries were
used to categorize clinical significance of the changes with respect to fall
risk. We have chosen to characterize the zone between high and low fall
53
risk as a transition or moderate risk zone. Thus the movement of each
individual performance can be observed from a perspective of increased
or decreased fall risk over time. For the Tango group (Figure 9a), eight
subjects improved their WWT times from pre- to post-evaluation. Of the
eight subjects, three individuals started out in the high risk zone at the pre-
evaluation. Two of these participants moved into the moderate risk zone in
the post-evaluation and the last one improved to the extent that this
participant landed in the low risk or non-fallers zone in the post-evaluation.
Two subjects showed no change and the time to complete the WWT for
three other subjects increased slightly in the post-evaluation. Overall,
there was a meaningful improvement for 62% of the subjects in this
cohort. When comparing baseline values with the follow-up scores, nine
participants improved the time to execute the divided attention task and
four subjects took longer to complete the task. Two of three individuals
whose baseline values placed them most at risk for falls were able to
maintain lower risk for falls into the follow-up period.
By contrast, in the Walk group (Figure 9b), there were only two
subjects who greatly improved (from high risk to moderate) while three
others showed slight gains in their time to complete the WWT at the post-
intervention time period. Two individuals had no change in their WWT
times from pre- to post-evaluation and three participants took longer to
54
complete the WWT in the post-intervention period. Overall, 45% of the
participants in the Walk group showed meaningful improvements in the
divided attention task. Examining baseline values with respect to the
follow-up evaluation scores, nine subjects ameliorated their time to
execute the divided attention task and two participants took longer to
complete the WWT than they had at baseline. As weil, the performance of
the task was highly variable in this cohort and did not show any specifie
trends throughout the study.
4.4.2 Working Memory
Using age-based norms, percentile rankings for working memory
scores were calculated. Prior to taking part in the study, the Tango group
was ranked at the 50th percentile and the Walk group was ranked lower, at
the 40th percentile (Figure 10). By the post-intervention evaluation, the
Tango group had an average ranking at the 56th percentile and the Walk
group at the 52 nd percentile. At follow-up, the Tango group ranked in the
57 th percentile and the Walk group stayed at the 52 nd percentile.
Therefore, both groups were able to move above the 50th percentile
ranking and to maintain these gains into the follow-up period. While this
effect was larger for the Walk group, the Tango group continued to
improve in the follow-up interval, while the Walk group remained at the
sa me level as at post-intervention.
55
ln Figure 11, histograms illustrate the number of individuals in each
cohort who showed gains or losses by score changes in working memory
for both post-intervention and follow-up with reference to baseline. In
general, subjects in both groups improved their baseline scores by at least
one point into post-intervention and follow-up periods, indicating a 45 %
decrease in driving risk for accidents (Lee et aL, 2003). When comparing
the overall gains made by each group from baseline to follow-up, 69% of
the Tango group and 63% of the Walk program had clinically meaningful
improvement of at least one mark higher on their composite Working
Memory score. However, the distribution of gains and losses in Working
Memory was much more variable in the Tango group than in the Walk
cohort for both intervals. As weil, there were more participants whose
scores decreased or did not improve following the Tango intervention and
into the follow-up as compared to the walk program. From baseline to
post-Tango, three subjects' scores decreased and two individuals showed
no change in Working Memory. In the Walk program, none of the subjects
had lower scores than baseline, although three individuals had no change
in their Working Memory values in the post-intervention evaluation. When
comparing follow-up values to baseline, the Tango group had four
participants who scored lower than their baseline values while only two
individuals in the Walk group fell into this category.
56
4.5 COMPARISON BETWEEN GROUPS
A series of 2 by 3 way repeated measures ANOVAs were
calculated in order to determine the differences between the two
intervention programs (Table 3).
4.5.1 Oivided Attention
There was no effect of treatment, however, there was a significant
effect in time (p =.014) but no significant interaction was observed.

No significant effects for treatment and time were found for Letter-
Number Sequencing and Spatial Span. Also, for both subtests of Working
Memory, there were not any significant interaction effects. For Working
Memory, no difference was found for the intervention between the groups
but there was a significant effect of time (p = .022) but not a significant
interaction effect.
4.6 EFFECT SIZES
As this was a feasibility study, effect sizes were also calculated 2 .
The effect sizes for each cognitive measure were calculated comparing
each group's means and standard deviations at the post-intervention
evaluation (Table 4).
2Effect size formula: rYI = d / O(d 2 + 4). http://web.uccs.edu/lbecker/Psy590/escalc3.htm.

Retrieved January 27th, 2007.
57
4.6.1 Divided Attention
A small effect size was found (r =.199) suggesting that there was a
14.7% non-overlap between the two distributions and that the mean of the
Tango cohort was at the 58th percentile of the Walk cohort.
ln terms of LeUer-Number Sequencing, no effect size was seen (r =

.004) indicating that the distributions of both groups completely overlapped
and that the mean of the Tango group was at the 50th percentile of the
Walk program. For Spatial Span, an effect size of 0.115 was calculated.
This signifies that there was approximately 7.7% non-overlap between the
Tango and Walk programs and the mean of the Tango group was at the
54 th percentile of the Walk intervention. Finally, an effect size of 0.077 was
found for Working Memory, suggesting that there is close to 7.7% non-
overlap between the two intervention programs and that the Tango group
was approximately at the 54 th percentile of the Walk group.
4.7 BOX-AND-WHISKER PLOTS
Box-and-whisker plots were used to examine the distribution,
variability and outliers for both intervention programs at pre, post and
follow-up intervals. In Figure 12, WWT distributions are represented. For
the Tango group, there was a decrease in the variability from baseline to
follow-up, and a decrease in the actual time it took for 75% of the
58
participants to execute the WWT to weil below the fall risk zone (15 sec).
Most of the variability can be found in the fourth quartile that extended into
the high fall risk zone for three participants. The Walk group increased in
variability at post intervention, while at the follow-up period, the box-and-
whisker plot more closely resembled that for the Tango group, although
the median was not skewed toward faster times as it was for the Tango
group.
The most interesting observations are related to the median scores
in Letter-Number Sequencing (Figure 13) Although the changes for the
Walk group were significant while those for the Tango were not, it can be
seen that the median scores for the Walk cohort were at 10 for both pre-
and post-intervention, while those for the Tango cohort moved up from 10
to 11. At follow-up, the median score for the Tango stayed at 11 while the
Walk group moved up to 11. Also, at baseline, the distribution for the
Tango group was spread out as compared to the Walk group whose third
quartile was equal to its median. Thus, the trend towards higher scores
was more prominent for the Tango cohort between pre- and post-
intervention while this trend was more prominent at follow-up for the Walk
group, reflecting a similar pattern to the divided attention task.
For both groups, the spatial span distribution showed considerable
overlap across time periods (Figure 14). However, as reflected in the
59
baseline p value (p = 0.12) the distribution for the Walk group was skewed
towards lower scores than those of the Tango group. In the post-
intervention period, there was an upward improvement in scores above
the median score for the Walk group. The Tango group did not experience
much change at the post-intervention evaluation, although there were
three outliers whose scores were lower th an the 1st quartile.
The working memory plots (Figure 15) illustrated the high amount of
overlap between the two interventions making them indistinguishable. The
median increased from 21 to 22 in the post-intervention for the Tango
group and from 20 to 21 in the Walk group. These shifts in the median
were maintained into the follow-up period. When comparing the pre- and
post-evaluation plots for the Walk group, we saw a decrease in the
variability, resulting in a much tighter distribution of scores in the post-
intervention.
60
Table 1. Baseline Measures
A. Subject Demographies by Group Allocation

Tango Group Walk Group p-value
Age (years)
Mean (SD) 78.07 (6.87) 74.64 (8.03) .26
Sex
Male:Female 3:11 2:9
MMSE
Mean (SD) 28.43 (1.74) 28.73 (1.42) .65
B. Baseline Outcome Scores by Group Allocation

Tango Group Walk Group p-value
WWT (sec)
Mean (SD) 18.14 (7.554) 18.95 (5.835) .77
Letter-Number
Sequencing
Mean (SD) 9.69 (2.097) 9.36 (2.420) .72
Spatial Span
Mean (SD) 10.38 (2.256) 9.09 (2.256) .12
Working Memory
Mean (SD) 20.08 (3.148) 18.45 (3.532) .25
Note. Ali p-values are two-tailed.
61
Table 2. Within Group Changes
Tango
Pre Post p-value FUP p-value
WWT (sec)
Mean 18.14 15.71 .017* 15.33 .036*
(SO) (7.554) (6.231 ) (7.213)
Letler-Number
Sequencing
Mean 9.69 10.38 .185 10.77 .08
(SO) (2.097) (2.755) (2.048)
Spatial Span
Mean 10.38 10.54 .388 10.62 .31
(SO) (1.710) (2.184) (2.329)
Working Memory
Mean 20.08 20.92 .173 21.38 .092
(SO) (3.148) (3.427) (3.885)
62
Table 2. Within Group Changes (continued)
Walk
Pre Post p-value FUP p-value
WWT (sec)
Mean 18.95 18.71 .408 16.91 .036*
(SO) (5.835) (8.401 ) (7.181)
Letler-Number
Sequencing
Mean 9.36 10.36 .017* 10.09 .1
(SO) (2.420) (2.292) (2.343)
Spatial Span
Mean 9.09 10.00 .06 10.18 .07
(SO) (2.256) (2.490) (2.359)
Working Memory
Mean 18.45 20.36 .002* 20.27 .019*
(SO) (3.532) (3.776) (3.552)
Note. Ali p-values are one tailed.

* p< .05
63
Table 3. Analysis of variance for the Two Interventions
Source dt F P
WWT
1ntervention 1 0.43 0.519
Time 2 4.74 0.014*
Interaction 2 0.96 0.391
Letter-Number
Sequencing
Time 2 2.46 0.097
Interaction 2 0.25 0.78
Spatial Span
Time 2 1.72 0.191
1nteraction 2 0.86 0.430
Working Memory

Time 2 4.15 0.022*
1nteraction 2 0.41 0.666
Note. Ali p-values are one tailed.
* p< .05
64
Table 4. Effect sizes
Tango Group Walk Group Effect

Size
WWT
Mean 15.71 18.71 0.199
(SO) (6.231) (8.401)
Letler-Number
Sequencing
Mean 10.38 10.36 0.004
(SO) (2.755) (2.292)
Spatial Span
Mean 10.54 10.00 0.115
(SO) (2.184) (2.490)
Working Memory
Mean 20.92 20.36 0.077
(SO) (3.427) (3.776)
65
Figure 5. Divided Attention Performance
Oivided Attention Performance
30~·--------------------------------------------------~
25
* *
*
20
Û
CIl
en
-; 15
E
i=
10
0
Pre Post FUP
Evaluation Period
This bar graph with standard error bars represents the average time (in
seconds) to complete the Divided Attention Task (black bars represent the
Tango cohort, and white bars represent the Walk cohort). An
improvement on this task is a DECREASE in the amount of time needed
to complete the task.
* indicate significance at p < .05 for a one-tailed t- test.
66
Figure 6. Auditory Memory
1 14
12
Auditory Memory:
Letter-Number Sequencing
1/1 10
I!!
0
u
If) 8
• Tango
".!:!
QI
oWalk
iij 6
E~
0
z 4
o
Pre Post FUP
Evaluation Period
Bars represent normalized scores (for age) for the auditory memory
component of the Wechsler Memory Scale-1I1. Conventions as in Figure 5.
* p< .05
67
Figure 7. Working Memory
Working Memory
30
1/)
~
0
25 * *
0
fi> 20
"0 • Tango
CI)
N
15
oWalk
ni 10
...0E 5
z
0
Pre Post FUP
Evaluation Period
Bars represent normalized scores (for age) for working memory of the
Wechsler Memory Scale-1I1. Conventions as in Figure 5.
* p< .05
68
Figure 8. Spatial Memory
Spatial Memory:
Spatial Span
fil 15
~
e
~ 10
'"C • Tango
Cl)
N
cv 5 DWaik
E
L-
e
z
o
Pre Post FUP
Evaluation Period
Bars represent normalized scores (for age) for spatial memory component
of the Wechsler Memory Scaie-ili. Conventions as in Figure 5.
* p< .05
69
Figure 9 (a). Divided Attention: Tango Group
Oivided Attention
Tango Group
40 ,---------------------------------------,
35 •
30 •
.............................+....................... ~ .................. .
o
~ 25
t/)
~------------------
o •• • Pre
o Post
,
;- 20 0 0 •
E 15
J-- • • •IJ ,
• 1
eFUP
10
5
o +-----------~------------~------------4
o 5 10 15
Subject
Individual scores are represented along the x-axis for ail participants in the
Tango group. Filled diamonds, clear squares and filled circles represent
pre-intervention (Pre), post-intervention (Post) and follow-up (FUP) values
respectively. The small dotted line (28.9 seconds) represents the
demarcation for high risk for falls while the large dashed line (20.1
seconds) signifies the boundary for low risk for falls (Verghese et aL,
2002). The area between the two dashed lines is a transitional area of
moderate risk for falls.
70
Figure 9 (b). Divided Attention: Walk Group
Divided Attention
Walk Group
40 ~------------------------------------~
35
~ 0
_ 30 .......................................................................... .
~25 0 • • Pre
~20~.-~-------------~- o Post
G)E. • 0 ~
- 15 • •• • • .FUP
~ • ~ D.
10 • 0
5
o +-----~----~----~------~----~----~
o 2 4 6 8 10 12
Subject
Individual scores are represented along the x-axis for ail participants in the
Walk Group. Conventions as Figure 9(a).
71
Figure 10. Working Memory
-------- - - - - - - - - - --- ---
Working Memory
70
60
50
.!
:;:;
40
cCI) • Tango
...
u
CI) 30
oWalk
D..
20
10
0
Pre Post FUP
Evaluation Period
Bars represent percentiles for working memory of the Wechsler Memory

Scaie-lii. Conventions as in Figure 5.
72
Figure 11. Changes in Working Memory Scores
(a) (C)
Changes in Working Memory: Post-Pre Tango Changes in Worklng Memory: Post-Pre Walk
5 4
J!l fi
~ 4 .!!., 3 -1
"E .Q r-- r-
~ 3
:::J
... • Changes in Working tn
'0 2-1 r-- ,--
0 Changes in Working
~ 2 Memory: Post-Pre ...III 1
Memory: Post-Pre
III
.Q .Q 1
E E
:::J
Z 0
:::J
Z 0 D
-6 -3 -1 0 2 5 6 a 2 4 5
Change in Working Memory Score Change in Working Memory Score
(b) (d)
Changes in Worklng Memory: FUP-Pre TANGO Changes in Working Memory: FUP-Pre Walk
4,-------------------------------,
fi fi 5
.!!., 4
~3 .Q
~ 3
:::J
tn • Changes in Working o Changesin Working
'0 2 .2
... Memory: FUP-Pre
.8 2
Memory: FUP-Pre
.!
E
:::J
E
:::J
Z 0 Z
0
-6 -2 -1 2 345 7 -2 2 3 4 7
Change in Working Memory score Change in Working Memory Score
73
Histograms showing the number of individuals who experienced the same
amount of change in working memory between pre- and post-intervention
(a,c) and pre- and follow-up (b,d). Negative values indicate a poorer score
from pre-intervention values, and positive values indicate an improved
score. Tango values are on the left side in black (a, b), while Walk values
are on the right side in white (c, d).
74
Figure 12. Box-and-whiskers Plots: WWT
40 ~--------------------------------------~
35
30
l! 25
3 20 1a Medianl
en 15
10
5
o +-----~------~----~----~------~----~
P re- Pre-Walk Po st- Po st- FUP- FUP-
Targo Targo Walk Targo Walk
Evaluation Period-Group
Boxes represent the spread of the 2 nd and 3 rd quartiles of each cohort.

Black boxes represent the Tango cohort while the white boxes represent
the Walk cohort. Medians are represented by triangles.
75
Figure 13. Box-and-whiskers Plots: Letter-Number Sequencing
LNS
16 ~-------------------------------------,
14
12
~ 10
oc,)
8 Il\Median 1
CI) 6
4
2
O+-----~------~----~----~------~----~
P re- P re- Post- Post- FUP- FUP-
Tango Walk Tango Walk Tango Walk
Eua luation P eriod-Group
Boxes represent the spread of the 2 nd and 3rd quartiles of each cohort.
76
Figure 14. Box-and-whiskers Plots: Spatial Span
Sp atial S pan
16
14
12
Q) 10
e
<.) 8 1 A Median 1
(/)
6
4
2
0
Pre- P re- Post- Post- FUP - FUP-
Tango Walk Tango We4k Tango Walk
Eva luation P eriod-Group
Boxes represent the spread of the 2nd and 3rd quartiles of each cohort.
77
Figure 15. Box-and-whiskers Plots: Working Memory
Working Memory
12
0
3J
U 15
CI)
25
2J
10
,. ~
., ~ I.l!.Median 1
5
0 .
Pre- Pre- Post- Post- FUP- FUP-
Tango Walk Tango Weik Tango Walk
Eva luation P erio~Group
Boxes represent the spread of the 2nd and 3rd quartiles of each cohort.
78
5. DISCUSSION
This feasibility study has demonstrated that both Walking and
Tango result in cognitive gains that persist for one month post-
intervention. These gains may be exercise specific as significant
improvements for only the Tango group were seen in the divided attention
task while the significant improvements for only the Walk group occurred
in working memory at post-intervention. However, caution must be
exercised in the interpretation of this limited data set as no significant
interaction effects were seen in the 2 x 3 way repeated measures
ANOVAs. Each cognitive skill will be discussed in terms of ail three
research questions.
5.1 DIVIDED ATTENTION
Significant improvements immediately following the Tango program
and persistence at one month after the cessation of this intervention
indicate that dancing the Tango effectively targets divided attention
capacity in seniors and does not decay for a one month period after
cessation of the activity. While it is possible that this cohort continued to
practice Tango during the one month interval before follow-up testing,
distance and cost for Tango schools in Montréal decreased the likelihood
of this. As weil, the Tango community in Montreal is sufficiently small, that
we were able to monitor this to our satisfaction. However, we were not
79
able to monitor the walk group as rigorously. Indeed several of the
participants mentioned in exit interviews that they had continued to enjoy
walks with their new friends in the follow-up period. The significant effect
(p = .036) observed in the follow-up evaluation for the Walk group
therefore might indicate that a lengthier program is necessary to observe
significant changes in this outcome measure. Alternatively, it might be a
function of a delayed effect. We hypothesize that it is the former
phenomenon. Therefore, we cannot unequivocally state that divided
attention was specifically addressed by the Tango intervention.
However, the magnitude of improvement experienced by the Tango
group was greater than that of the Walk program for the pre- to post-
interval and persisted into the follow-up period. The average time to
complete the WWT from baseline to follow-up decreased from 19 seconds
to 17 seconds for the Walk group whereas the Tango group average time
decreased from 18 seconds to 15 seconds. Concomitantly, only the Tango
cohort demonstrated meaningful clinical improvements. As can be seen
from Figure 9(a), those subjects with the greatest risk for falls in the Tango
group were able to improve the time it took them to accomplish the WWT
from pre to post-evaluation, moving them from the fallers zone into the
transitional area and even into the nonfallers zone. These results indicate
that the individuals who were the most at risk showed the greatest benefit
80
by decreasing their risk for falls in a clinically significant manner. Also,
those participants in the Tango group who were in the nonfallers zone in
the pre-evaluation period showed improvements in the WWT. In contrast,
this effect was not observed in the Walk group. Those with the greatest
risk for falls in the Walk group failed to improve and took longer to
complete the WWT in the post-evaluation as compared to their pre-
evaluation times.
This being said, our results do suggest that walking may increase
the ability to perform divided attention tasks, but that the response may
require a longer time period to emerge. This phenomenon may be due to
the fact that our subjects were asked to walk in novel surroundings rather
than in the mali or on a treadmill. It is possible that each of these
paradigms may convey different benefits to physical, social and cognitive
health. For example, treadmill walking may be the best choice for
increasing aerobic fitness or training walking patterns, as the individual is
constrained to walk at a specifie speed for the duration of the exercise.
Walking freely in a mali or park permits one to stroll at a varying pace that
is not always conducive to aerobic training, but may afford other
advantages, especially those in the social and cognitive domain.
Treadmill walking is often used in rehabilitation programs for stroke
patients to force the individual to walk at a specifie pace (Daly, Roenigk,
81
Holcomb, Rogers, Butler, Gansen, McCabe, Fredrickson, Marsolais, &
Ruff, 2006; Macko, et aL, 2005), and music cueing using rhythmic auditory
stimulation while walking has been shown to help Parkinson's patients
normalize gait parameters during corridor walking (Mclntosh, Brown, Rice,
& Thaut, 1997).
By contrast, overground walking has been shown to have more
positive benefits as an exercise activity than treadmill walking in the
geriatric population (Marsh, Katula, Pacchia, Johnson, Koury, & Rejeski,
2006) because of the added social component. For example, one report
suggested that older adults saw mali walking as a way to socialize and
make new acquaintances in a safe surrounding (Travis, Duncan, &
McAuley, 1996; Duncan, Travis, & McAuley, 1995). These authors
postulated that taking part in mali walking gave the seniors a routine to
adhere to and a sense of belonging. It is possible that walking in novel
environments provided additional cognitive stimulation.
Thus it can be argued that attentionally challenging locomotor
activities are critical for improvement in this function, and the more
challenging the activity, the more rapid and large are the gains. This
hypothesis is supported by the InCHIANTI study (Ble et aL, 2005) where it
was determined that executive functioning (and therefore divided
attention) is intricately related to the performance of attentionally
82
challenging lower extremity mobility activities in the healthy community
dwelling geriatric population. Indeed, Hausdorff, Yogev, Springer, Simon,
& Giladi (2005) found that performance on the Stroop test, which taxes
decision making abilities and reaction time parameters of executive
function, was correlated with the gait parameters of stride time and
variability. They further suggested that walking is more cognitively
complex than one might suspect, as it demands input trom executive
functioning. This is consistent with research concerning the gait patterns of
Alzheimer's patients. When forced to divide their attention between motor
and cognitive tasks, Alzheimer's patients are less able to properly regulate
their stride-to-stride variability while walking (Sheridan, Solomont, Kowall,
& Hausdorff, 2003). These results further emphasize the importance of
finding an intervention that targets divided attention in older adults in order
to prevent the decline in executive function associated with normal aging.
Poor executive functioning skills could lead to the inability to quickly
process and plan motor responses in complex attentional situations.
With respect to divided attention, one has to ask why the Tango
cohort responded more rapidly and vigorously to this divided attention task
than the Walking cohort. It is not unusual to have a conversation with a
friend, colleague or family member while walking. Be it to the cafeteria,
grocery store or even movie theater, walking while talking with a
83
companion is a routine activity. Therefore walking with a companion may
not necessarily promote the development of divided attention skills as
rapidly as dancing. As mentioned previously, the spontaneity and
improvisational nature that is inherent to the Argentine Tango, combined
with the necessity of being aware of the other couples on the dance floor
and the signais from one's partner, increases the cognitive load whilst
dancing. It is therefore understandable that Tango dancing as an
intervention is more responsive than walk for enhancement of walking
while talking as a measure of divided attention.
5.2 WORKING MEMORY
Two individuals in the Tango group had scores that were 6 and 7
points below baseline at post-intervention and follow-up, respectively. As
these were outliers (Figure 11), we took a close look at their folders to see
if there had been a significant event that might have affected their
performance. One subject contracted shingles during the latter part of the
intervention and was still symptomatic in the follow-up period, while the
other subject had a close family member who had been diagnosed with a
terminal iIIness during the follow-up period. Given the nature of these
traumatic physical and emotional events, we re-examined the data
pertaining to the composite working memory score when these two
subjects were eliminated from the data base as chronic pain and
84
emotional distress may affect performance on the working memory tests
(Dick, Eccleston, & Crombez, 2002). The paired t-tests were re-calculated
for working memory without these two subjects. The paired t-tests showed
significant differences from baseline to post-evaluation and follow-up (p =
.008 and p = .009, respectively), thereby indicating that when these
outliers were excluded from the sample the Tango intervention had
positive effects on Working Memory that were seen in the post-
intervention and persisted into the follow-up period. The histograms now
showed that only one person performed poorly in the post-intervention as
compared to baseline performance, two subjects showed no change and
eight participants improved, a clinically meaningful improvement in 72% of
subjects (Figure 16a). When looking at working memory scores at follow-
up evaluation, two subjects had worse scores and nine improved (Figure
16b). While there was a significant effect of time (p = .001) in the re-
calculated ANOVA, no significant interaction effect was seen for Working
memory. While there were three subjects in the Tango group who
improved greatly (gains of 5 points or more), and although such large
gains seem relatively unlikely, there was nothing in their files to suggest
why this would be so. Perhaps these individuals were having health
problems at baseline, so that the post-intervention and follow scores more
truly reflect their performance abilities. Thus we suggest that in future
85
studies with this age group, it would be helpful to administer a Health
Status visual analogue scale in order to document the subject's perception
of their health at the time of testing. This information would allow us to
gauge how reliable their performance is and identify any confounders.
Another aspect that should also be considered is related to their
psychosocial affect. Although we have reported that sense of weil being,
loneliness and social provisions did not correlate with performance on the
working memory tasks for the two cohorts combined (Jacobson, McKinley,
& Rainville, 2006), the two individuals who were outliers for working
memory in the Tango cohort did show striking decreases in the social
provisions scale and sense of weil being (Appendix 4), suggesting that this
aspect also needs to be considered when performance is drastically
changed. It is important to remember that while the results for either cohort
could not be considered statistically significant, we found clinically
significant improvements in the composite working memory scores. The
majority of subjects in both groups showed positive improvements of at
least one point on working memory in post-intervention and follow-up
evaluation (Figure 11) as compared to baseline, signifying substantial
reduction in the risk for being in a car accident (Lee et aL, 2003).
Although the paired t-tests for both post-intervention and follow-up
for the Walk cohort approached significance but not those of the Tango
86
group (Table 1), at baseline the two groups were close ta being
statistically different ( p = .12). The box-and whisker plots for spatial
memory (Figure 14) showed that while the distributions for the Tango
group at each time interval overlapped, the improvement shawn in the
Walk group did not exceed the values of the Tango group. It is possible
that a ceiling effect might exist that would prevent scores from improving
as much in those age-based norms where scores are already above the
50th percentile at baseline. Spatial span is more adversely affected by age
than other WMS-III subtests (Myerson, Emery, White, & Hale, 2003); it
undergoes a linearly decreasing trend with age (Park, Lautenschlager,
Hedden, Davidson, Smith, and Smith, 2002), raising the possibility that
early on in adulthood, the capacity ta retain spatial information is
negatively affected by the aging process (Myerson et aL, 2003). As weil,
spatial span is also a measure of fluid intelligence which is known to
decrease with age, making improvement harder to observe (Baddeley,
1999). Our results indicate that neither Tango dancing nor walking
significantly enhances spatial memory in older adults, which is consistent
with current cognitive thought that working memory deteriorates as people
grow aider. More research is needed in order to understand whether
spatial memory can experience measurable gains in the elderly, or
stabilize rather than decline with age.
87
The effects of an exercise intervention on working memory have not
been weil addressed in the literature. One study that did test working
memory compared older adults in the community who vigorously
exercised to sedentary individuals (Clarkson-Smith, & Hatley, 1989).
These authors observed that those who exercised performed significantly
better on cognitive measures which included reasoning, reaction time and
working memory. However, as the study relied on self-report of exercise
intensity and duration only, there is no information on the types of exercise
or on the actual fitness of these individuals. Therefore, the specifies of the
exercise effect in this study are not clear eut.
Two other studies that specifically evaluated physical activity and
cognitive function assessed either enhanced memory span and reaction
times (Williams, & Lord, 1997), or orientation, concentration, remote and
recent memory (Verghese et aL, 2003) but not working memory. Both
studies found that exercise was useful in enhancing cognitive function.
Williams and Lord (1997) found that women randomized to a group
exercise program had enhanced memory span, reaction times and
measures of well-being, as compared to the women in the control group,
while Verghese et al. (2003), using the Blessed information memory
concentration test to correlate cognitive decline and physical activity,
found that dance was the only physical activity that lessened the risk of
88
developing dementia. Thus, the beneficial effects of exercise on cognition
are beginning to emerge. Our study is the first to show that exercise,
specifically walking, can enhance working memory in seniors.
5.3 SAMPLE SIZE
A critical issue for the future randomized clinical trial is the number
of subjects recruited to take part in the study. As expected, some people
withdrew from our feasibility study because they were not assigned to the
Tango intervention. Also, upon further investigation, two extremely
negative outliers in the working memory task were found to have
confounding circumstances that called for reevaluation of the data without
these two subjects. It is imperative that while planning a study where the
target population is the elderly, the research team ensures that enough
subjects are recruited beyond the calculated sam pie size because growing
older creates situations that affect and can confound one's analysis and
interpretation. As can be seen from Table 4, when comparing post-Tango
and post-Walk values, a small effect size (r = .199) for divided attention
was found. An effect size of 0.199 implies that there is 14.7% non-overlap
between the two distributions and that the mean of the Tango group is at
the 58th percentile of the Walk group. In order to find a statistically
significant result in the future, there needs to be approximately 395
subjects in each intervention program.
89
5.4 CLiNICAL IMPLICATIONS
Older adults may benefit from a variety of different exercises, each
one having their own specifie effect on cognition. This study demonstrates
that both Tango dancing and walking result in specifie positive gains on
older adults' cognitive skills. As weil, it is suggested that the more
challenging the activity, the more responsive the individual is to the
intervention. Both Tango and Walk programs were challenging in different
ways. Our Walk program was specifically designed to avoid drop-outs by
walking in parks, botanical gardens and nature preserves with the goal of
combining physical activity with social interaction. Each session was more
like an excursion to a new environ ment where the participants had to way
find in a stimulating and ri ch surrounding. These enriching experiences
might explain the cognitive gains seen in this study. This could be an
important feature which requires further consideration. Indeed there is a
paucity of information related to development of cognitive skills and
physical activity, including walking. Most of the studies have addressed
correlations between decline in cognitive function and decline in specifie
gait parameters such as stride length (Sheridan, et aL, 2003), speed (Ble
et aL, 2005), or variability (Springer et aL, 2006), or divided attention
performance and moving over and around obstacles (Brown, McKenzie, &
Doan, 2005). The two studies that did assess the effect of physical activity
90
on slowing the decline in cognitive function over the long term (6-15 years)
used questionnaires (Weuve et aL, 2004) or self-reported number of
blocks or flights of stairs walked (Yaffe et aL, 2001) to compare changes in
cognition with respect to estimated exercise. Thus, to our knowledge, this
is the first study to specifically address walking as an intervention aimed to
improve cognitive skills in the elderly. This is important, as group walking
in novel environments is an activity that can be easily incorporated into
most community centers. However it should be emphasized that the
social component and novel stimulating environments may be key
elements for clinical gains in cognition.
Similarly, research utilizing dancing as a form of intervention in the
elderly has been sparse and the little that has been published focused on
the effect of dancing on balance or in patients with dementia. One pilot
study (Rosier et aL, 2002) established that learning to dance the waltz
helped Alzheimer's patients with their ability to learn motor ski Ils. Another
preliminary study (Hokkanen, Rantala, Remes, Harkonen, Viramo, &
Winblad, 2003) used a dance/movement therapy training for patients with
dementia to determine if this program would help improve these subjects'
verbal and cognitive status and behavioral symptoms. The
dance/movement therapy seems to positively affect the subjects' language
skills, as they produced more information units after the dancing sessions.
91
While no change was seen in terms of cognitive level, Hokkanen et al.
(2003) ascertained that this was a positive finding because of the
expected decline of cognitive function associated with dementia.
Behavioral symptoms stayed relatively unchanged. One recent study
(Shigematsu, Chang, Yabushita, Sakai, Nakagaichi, Nho, & Tanaka, 2002)
concluded that an aerobic exercise program based on dancing improved
certain measures of balance and locomotion in older women. Another
study (Federici, Bellagamba, & Rocchi, 2005) employed Caribbean
dancing as an exercise intervention for the "young old" men and women
aged 58 to 68, and found that the Caribbean dancing exercise program
improved balance in this cohort of subjects. As the dancing exercise
component is not weil described in these studies, it is not clear whether or
not these interventions include dancing with partners or as individuals. In
balance studies, they appear to resemble more closely the individually
oriented type of dancing found in aerobic dancing exercises. Thus the
cognitive load of interacting with a partner may not be a fundamental part
of these programs. The only study where it is clear that couples danced
together is that of Rosier, Seifritz, Krauchi, Spoerl, Brokuslaus, Proserpi,
Gendre, Savaskan, & Hofmann (2002). Unfortunately, no follow-up
measurements were reported for these studies, thus whether these gains
persisted is not known. As weil, there were no other comparable studies
92
that evaluated the effect of dancing on cognition in the healthy community
dwelling elderly. Thus, to the best of our knowledge, this study is breaking
new ground in the area of cognition and exercise. However, as this was
only a feasibility study, we must be cautious and not overemphasize the
results. Further studies with a larger sample size will confirm or reject our
findings.
An added benefit of the Tango is that the movements are
performed to music, which is known to facilitate performance of
ambulatory activities in neurological movement disorders such as
Parkinson's, stroke and cerebral paisy as weil as in healthy older adults
(Thaut, 2005; Thaut, Mclntosh, Prassas, & Rice, 1992). As such, adapting
Tango dance programs for the needs of persons with inner ear problems,
multiple sclerosis, Parkinson's disease or following a stroke could be
developed. Also, further research can investigate the assessment of
possible teaching methods that are the best for retention of steps,
engagement and sustainability of the dance program in the senior
population, and the development and testing of a universal Tango
instruction kit that can be used in senior community centers world-wide.
Lastly, but importantly, this program was proven to be self-sustaining. At
the end of the follow-up period our subjects were offered a choice of taking
the walk program or continuing with the Tango dancing, and ail chose to
93
continue Tango dancing. Due to the popularity of the Tango classes, the
community center has continued to offer Tango lessons at a nominal cost,
and this dance class is now a regular part of their activity program. Thus
this activity engages the elderly and is sustainable in the community
setting.
5.5 CONCLUSIONS AND SUMMARY
ln conclusion, our research shows partial support for the research
hypothesis that specificity of exercise relates to improvement in different
cognitive abilities. This can be seen by the significant gains in divided
attention for the cohort that practiced Tango as compared to the significant
gains in working memory for those who engaged in the Walk program. As
sample sizes were small, however, it is difficult to state unequivocally that
each exercise was specifie to a particular cognitive skill. As weil,
evaluating the literature concerning exercise and cognition is particularly
difficult as there is a wide variety of types of exercise employed as an
intervention from strength training to dancing, a large number of cognitive
skills and measures examined and different age groups targeted in the
elderly population. There is a real need to develop a standardized battery
of cognitive tests to allow for study comparisons as weil as truly determine
which exercises specifically serve different cognitive skills. A meta-
analysis could elucidate which exercises have been used and produced
94
positive gains in cognition as weil which cognitive skills and measures
were examined in arder to create a springboard far future research.
5.5.1 Limitations
Our study has a few limitations. Firstly, it was a feasibility study
conducted with a relatively small number of participants. Our findings need
to be replicated with a larger sam pie size. Also, ail the subjects
volunteered to take part in this study because they were interested in
learning how to dance the Argentine Tango.
5.5.2 Future Directions
This study needs to be replicated with a larger sample size in order
to accurately determine the effect of such exercise interventions. Future
studies could explore the effect of different types of dance as compared to
Argentine Tango on various cognitive skills, including divided attention and
working memory.
95
Figure 16. Changes in Working Memory without the two outliers
(a) 1 Changes in Working Memory: Post-Pre

Tango
~ 5~,--------------------------~
o li 4
~
E
.!. 32 i-1
.Q _ _
l ,- Changes in Working
Memory:Post-Pre
:::s ::J 1
ZUl
O
-1 o 1 2 5 6
Change in Working Memory

Score
Change in Working Memory: FUP-Pre Tango

(b)
4,
~ 3
'E
:;,
UJ 2 • Change in Working
'ô Memory: FUP-Pre
~
~ 1
E
:;,
z 0
-2 -1 1 2 3 457
Change ln Worklng Memory Score
96
Histograms showing the number of individuals who experienced the sa me
amount of change in working memory between pre- and post-intervention
(a) and pre- and follow-up (b) after removing 2 subjects who were
considered extreme outliers. Negative values indicate a poorer score from
pre-intervention values, and positive values indicate an improved score.
Tango values are on the left side in black (a, b)
97
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111
APPENDICES
APPENDIX 1: Recruitment Ad p.113

APPENDIX 2: Ethical Approval p.114
APPENDIX 3: Informed Consent Form p.116
APPENDIX 4: Social Scales p. 122
112
APPENDIX 1: Recruitment Ad
FI'IIUII#)~NJ1.o~N~~J#~ülllIl:lIlIJJl:lIlUIl:lIl:U1~lIl1l;lIlI#n.QlIi
n R
Il
Il
GNlII JUIF aM'4IN(l$ P'OOII\II\II$
CUWoIItoIGS IMi$Ii alll.,. POli SINIOIS
t
..,
J SPECIAL RESEARCH PROJECT i

:I~ Can Tang:~:/~~8 Classes .rI,. 1
i
i A Walking Group
Improve your Balance and Mobility?
~
i.\. t
IF VOU.... Ii
JJ)
.,. ARE IN PREITY aOOD HEALTH
.,. HAVE FALLEN AT LEAST ONCE IN THE LAST YEAR
.,; HAVE 2 AFTERNOONS FREE FOR 10 WEEKS
l)
t
1
1 1 Then you rnay be eligibje to participate in a special research project
it
Il desrgned to Improve your balance and mobility 1
D f For purposes ofthe study. you will be plaœd at random in either Tango hl
) Dance Cfa$S8$ or in aWalking Group f~lowed by tango lessons.
J NO PARTNERS REQUIREOI Î
ii WHEN:
WHER.E:
Spring 2004 (_ct date TBA)
Cummings Jewish Centre for Seniors
1
il
i 5700 Westbury Ave. 15
J) FEE: CJCS Members - No Charge Il
t
!: -Registration Necessary
J
1
i
NON.-MEMBERS: Fees paid by the raseareh project
For Infonnatlon Contact the Pmject Director

,Pa~ MÇ~7=:-::: Extension 352
11
IR
l5 ~~~"";,"'"
"'-- O:"Mt~"c~-I~lhboldll~ .,...\~!,~... ,.
........_-*. __. - •. - ~
....
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li
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113
APPENDIX 2: Ethical Approval
..•. ,'ot' ,! \ <.
Certijlcat d /éthique
Par la prêscnt~ le â;mlÎ,té û'.:thÎque de la NCbmlhc des 6tabIiSSCIllents du CRIR.(CEll)
attœte qu'U a Mlu6lc projet de rœhetthc in~tu16:
« The use or argeo.tine tango tblnœ to ptomote JOclaliz.ation, enbanee4

balaDce and mobillty, and cogllitiou iD: elderlyÛl traMitioa to Crailty)l).
Pmœté par: Patrlda Mc:KiDIey
NOM mm
Mp:I.elsabdlo Bi10dcau Uoc pcno~ ~ vue vaste
oooaQsStUlOQ du domaiœ ~al
eh r!àdaptation
MmcNirol-Korn«·BiteDsky Une pen:onnc po$$édant W'lC vasto

œmaissaoœ du domaine bimn6dic:a1 en
CIl~OB
Mme Ju1ic)-Annc Couturier Clinicienne cS!tecant une vaste

QODOàÎ$$a'OCo des ~ :iCIl5Odc1 visucla
ou.aoditi&
Mme Marie-Jo&6e Drolet Clioîcienno détenant une VNte
coriDais.saw;ç dcsdêflcitsmotcurs ou
neuroJ0si4ues
Mm~ Marie-Evc Bauthinicr Une persoooe spéei.ali$ée en ~lhiquo
Me Miellel GÎWux Une per.;oone sp6eial!sOo lm d:roit
M. André Vincent Une pcraoone non affili~d rétablissement

et ptOVenant del. dientèle déS pet'SOlUleS
adu~ et ap,"
114
APPENDIX 3: Informed Consent Form
~
CRJA. constance-Iethbridge ..
(·f1I'R~().RiAO ...FrArIf)N-!rIIiAElIU1Arm"(l.rItE
;;';~,:,.;",,:'~:::::''''
;1-" ,A. \q> •• ,_:;_ ";,,I.~
'" Cer>tre de ""hetthe
interdisciplinaire
en réadaptation
du Montréal métropolitain
INFORMED CONSENT TO PARTICIPATE IN A STUDY ON THE USE OF

ARGENTINE TANGO DANCE EXERCISES TO PROMOTE
SOCIALIZATION, ENHANCED BALANCE AND MOBILITY AND
COGNITION IN THE ELDERLY.
l, the undersigned, _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Consent to participate in the research study entitled: The use of argentine
tango dance to promote socialization, enhanced balance and mobility, and
cognition in: elderly in transition to frailty.
Research co-ordinators: P. McKinley, K. Berg, J. Fung, A. Leroux, C.
Rainville and M. Rossignol.
Objective of the research study
The objective of the study is to assess the feasibility of tango dance as a
physical and social activity for the elderly.
Participation in the study / Nature of my participation
1. Pre-exercise participation
o 1 will be assigned to either a walk group or a tango group. If 1 am
assigned to the walk group, 1 will be offered information about tango
courses in the community at the end of the study.
o 1 am required to attend an information session regarding the study,
where 1 will be informed about the exercise sessions and the study. At
that time 1 will be asked to fill out sorne questionnaires regarding my
feelings of happiness, loneliness, my social support system and
116
satisfaction with my life 3 . As weil, 1 may be asked to participate in
some tests conducted by a neuropsychologist.
D Within the next week, 1 will be asked to go to either the Constance
Lethbridge rehabilitation Centre (CLRC) or the Jewish Rehabilitation
Centre (JRH)for a functional evaluation of my balance. This evaluation
will be under the direction of a licensed physiotherapist and will take
approximately 1 hour.
D If 1volunteer for the dynamic balance tests 1will go to the JRH in Laval.
ln addition to the functional evaluation of my balance tests, 1 will
participate in tilt tests on a motion platform where 1will be placed in a
safety harness while asked to maintain upright two legged stance while
experiencing a tilt in 8 directions. This extra testing will take
approximately 1 hour.
2. Exercise Participation
If 1am assigned to the TANGO GROUP:
D 1 will then be required to attend the tango dance exercise classes
for the following ten weeks. The classes will be held two times per
week, and each session will be one and one half (1 1/2) hours long.
The classes will consist of warm up exercises, individual practice of
the steps in a group, and then with partners. 1will be taught by an
experienced tango dance instructor and her assistants. 1 may be
asked to switch between being the leader and the follower, so that 1
learn both aspects of the dance. There will also be a health
professional in attendance at ail the classes to assist me, if 1require
help. If 1do not feel like dancing with a partner during the "couples
practice", 1 may continue the exercises on an individual basis, or
with an instructor or aide as a partner.
D 1 will be required to attend at least 17 of the 20 exercise
sessions to stay in the project.
3 This meeting will take place at the Cummings senior Centre.
117
D 1will be required to participate in group discussion at the end of
each tango class where 1 will be asked my frank opinion about
the class content.
D At the end of the exercise classes, 1will be given information regarding
places where 1 might continue to learn the tango or practice what 1
have learned. 1will be asked to fill out a satisfaction questionnaire, and
other questionnaires concerning my global health status.
If 1am assigned to the WALK GROUP
D 1will be asked to walk at least for 15 minutes per day, on days when 1
do not attend walking sessions, and to attend at least 2 supervised
walking sessions per week with the exercise science student-
supervisor. 1will be asked to try to walk a total of 3 hours per week. If 1
am assigned to the walking group, 1 will be offered a tango course at
the Cummings Senior Centre at the end of the study.
D 1will have to monitor my daily activity with a log-book
D 1will have to attend 3 social sessions at the Cummings Centre
D 1 will have to maintain 3 hours of walking per week for at least 7 of
the ten weeks, or 1will be dropped from the study.
Post exercise session ail participants 1/ Post exercise session

for ail participants
D 1. Within a week after the la st class, 1 will be asked to return to the
CRCL (unless 1 am one of the volunteers for testing on the motion
platform) to re-do the functional balance tests and to answer the
questionnaires. This will take approximately an hour of my time.
D 2. If 1 am part of the group with testing on the motion platform 1 will be
asked to return to the JRH to re-perform the functional balance tests
and the dynamic balance exercises. This will take approximately 2
hours of my time.
118
o After a period of approximately three months, 1will receive a phone cali
to make an appointment for a third evaluation of my functional balance,
and to fill out the questionnaires one last time as in step 1 and 2 above.
Thus the total time that 1 will be asked to participate for this study is
approximately 50-55 hours in tango class or walking and social events,
and 4.5 hours of testing at the CRCL and if 1form part of the group tested
on the motion platform, 7.5 hours of testing at the JRH.
o 1 will be provided directly taxi cab service to either the CRCL or the
JRH.
Disadvantages for participation in this study
The principle disadvantage of participating in this study is the time that it
will take for participation in the classes and in the functional measurement
assessment, and answering the questionnaires. When performing some
of the tests, 1 might feel fearful of losing my balance. However, the
physiotherapist will be there to reduce my risk of falling. If 1 volunteer for
testing with the motion platform, 1 will be placed in a harness, suspended
from the ceiling to make sure that 1do not fall. There is also the possibility
that 1 may lose my balance during performance of the dance exercises.
However, 1 will have the option of using a "barre" (support rails), cane or
other walking aid, for performance of some of the exercises if 1prefer.
Advantages for participation in this study
There is the possibility that my balance will improve and my fear of falling
may diminish. While we do not know whether the tango exercises are
better or worse than walking exercises for improving balance or reducing
fear of falling, the information obtained from this study will help to better
serve the needs of the elderly who may be at risk for falling, by giving
them a choice of exercises in which to participate.
Confidentiality of information
1 have been assured that the information collected from this study will be
held in strictest confidence and will not be used except for research
purposes. To this end, my file will be coded in a way that will insure
119
anonymity and any published results will be presented with complete
anonymity. The personal data sheet (e.g. address and telephone number)
will be kept in a separate file folder, accessible only by the researchers
responsible for the project. This information will be destroyed at the end of
the project.
Ethical considerations
If 1 have any concerns regarding ethical questions and my participation in
this study, 1 may discuss these with the research co-ordinator at the JRH,
or CLRC, Ors McKinley or Fung.
Questions concerning this study
1 understand that 1 may ask ail my questions regarding this study and they
will be answered; these questions may be addressed to Dr. McKinley, Dr.
Berg, Dr. Fung, Dr. Leroux, Dr. Rainville, or Dr. Rossignol.
Responsibility clause
ln accepting to participate in this study, you will not relinquish any of your
rights and you will not liberate the researchers nor their sponsors or the
institutions involved from any of their legal or professional obligations.
Contact person
If you have any questions concerning your rights and your recourse or on
your participation on this research project, you can contact Me Anik Nolet,
coordonnatrice à l'éthique de la recherche des établissements du CRIR at
(514) 527-4527 extension 2643 or by email at the following address: :
anolet.crir@ssss.gouv.qc.ca.
Responsibility of the principal investigator
l, the undersigned, , certify that (a) 1 have
explained to the participant the terms of the present agreement, (b) 1 have
responded to ail the questions posed to me (c) 1have clearly indicated that
the participant is free to leave the study described above at any time (d)
and that 1will give him a signed and dated copy of this form.
Withdrawal fram the study
120
1 understand that my participation in voluntary, and 1 may withdraw fram
the project without prejudice, penalty or loss of service or benefits in the
community or in the health system.
signature of participant signature of witness
Date
1 (co-ordinator) _ _ _ _ _ _ certify that 1 have explained to the above

mentioned participant the nature of the study, the known disadvantages
for participation, and that the participant may withdraw from the study at
any time. 1 have assured the participant that the information obtained in
the study will remain confidential.
Signature of coordinator Date _ _ _ __
Project co-ordinators:
Patricia McKinley, (514) 487-1891, ext.: 352

Joyce Fung , (450) 688-9550, ext.: 429
Michel Rossignol, (514) 528-2400, ext.: 3261
Constant Rainville, (514) 340-3540, ext.: 4022
Alain Leroux, (514) 848-2424, ext.: 3326
Katherine Berg,
121
APPENDIX 4: Social Scales
UCLA Loneliness scale (revised) (Russell, 1996) is considered the go Id
standard of loneliness measures and is a 20-item scale ranging from 20-
80 with internai consistency ranging from a =0.89-.94; construct validity is
supported by significant relations with measures of adequacy of the
individual's interpersonal relationships, and be correlations between
loneliness and measures of health and well-being. The French version
(De Grace, Joshi, & Pelletier, 1993) shows comparable validity, test-retest
reliability and internai consistency.
Social Provisions Scale (SPS) (Cutrona, & Russell, 1987) takes 15
minutes to complete, consists of 24 items using a Likert scale to
measure 6 dimensions of social support: emotional support, aid,
counseling, social integration and need to feel useful and necessary The
authors concluded that the SPS assesses both specifie components and
overall levels of social support. Internai consistency for the total SPS
ranges from a= 0.83-0.90. A French version with comparable
psychometries is available (Caron, 1996; Tempier, Caron, Mercier, &
Leoffre, 1995).
Satisfaction with life Scale (SWLS) (Diener, Emmons, Larsen, & Griffin,
1985) consists of five statements with a 7 point scale indicating the
amount of agreement (7 = strongly agree) or disagreement (1 = strongly
disagree; 4 = neither agree or disagree). Initial and subsequent studies
have examined the internai consistency and alpha coefficients have
repeatedly exceeded 0.80 (Pavot, & Diener, 1993). It has good construct
validity. Test retest reliability is high (r = 0.89) within a two week period,
but declines as time increases, suggesting that the instrument is sensitive
to changes that occur with life and not just a direct effect of stable
personality traits. It also shows consistent differences between populations
that would be expected to have different qualities of life (psychiatrie
patients, or male prison inmates), and has been found to change in the
expected directions in response to major life events (Pavot, & Diener,
122
1993; Vitaliano, Russo, Young, Becker, & Maiuro, 1991). A French
version with similar psychometrie properties is available (Rolland, 1998).
123

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Specificity of Exercise on Enhancing Cognitive Abilities:

Argentine Tango and Walking

Allison Jacobson, B.Sc. (Psychology)

A thesis submiUed to McGiII University in complete fulfillment of the

© Allison Jacobson, 2006

Published Heritage Direction du

395 Wellington Street 395, rue Wellington

Your file Votre référence

The author retains copyright L'auteur conserve la propriété du droit d'auteur

ln compliance with the Canadian Conformément à la loi canadienne

While these forms may be included Bien que ces formulaires

or Walking on cognition. Thirty healthy community dwelling seniors (60+)

post-intervention and follow-up on divided attention (Walking-While-

significantly improved divided attention capabilities while the Walk

program significantly improved working memory. These findings need to

be replicated with a larger number of subjects.

L'objectif de cette étude de faisabilité était de déterminer les effets d'un

programme de 10 semaines de Tango argentin ou de marche sur les

fonctions cognitives de personnes âgées à risque de chutes. Trente

personnes âgées en bonne santé et de la communauté étaient recrutées

pour assister à l'étude. Ils étaient évalués au niveau de référence, post-

intervention et suivi sur des tâches d'attention partagée (parler en même

temps que marcher) et de la mémoire de travail. L'étude a trouvé que la

danse Tango a significativement amélioré les capacités d'attention

partagée alors que le programme de marche a significativement amélioré

la mémoire de travail. Ces résultats doivent être répliqués en utilisant un

plus grand nombre de participants.

the journey that blossomed into my Master's thesis as weil as a wonderful

learning experience. 1 feel fortunate to have been involved in this unique

First and foremost, 1 wou Id like to thank my supervisor, Dr. Patricia

supporting and guiding me. Her comments and feedback played an

invaluable role in the progression of my thesis and 1 am truly grateful for

to scientific research. On a more personal note, Dr. McKinley's continued

belief and confidence in my various endeavours outside of the realm of my

thesis have meant the world to me, especially in my pursuit of a clinical

1 would also like to acknowledge the members of my Thesis Supervisory

During my Master's degree, 1 was fortunate to receive several different

sources of funding for research and conference attendance. 1would like to

thank the Social Sciences and Humanities Research Council of Canada

and Occupational Therapy of McGiII University in the form of a travel grant

abstract for my project was selected as one of six presented at the

Society's press conference in Washington, D.C in November 2005. Grants

International Congress Gait & Mental Function in Madrid, Spain in

Thank vou to the participants for volunteering to be part of this adventure.

Special thanks to Lucie Bouvrette, Victoria Bednarczyk Sheila Schneiberg,

Julie Lamoureux and Eve-Marie Quintin, your knowledge in statistics and

willingness to answer ail of my questions was indispensable.

support, without which 1 would not be where 1 am today. A very special

their patience and encouragement.

The Canadian society is growing older each year as the number of

seniors living is increasing at a higher rate than their younger

counterparts. To keep older adults physically and mentally healthy, it is

physical activity helps to maintain seniors' quality of life and

independence, as their health is intricately related to their independence.

because if seniors do not stimulate their cognitive and physical faculties,

they will experience measurable decline in these abilities. However,

despite government initiated programs to raise awareness about being

active and pro-exercising advertising campaigns, approximately 60% of

older adults in Canada are physically inactive (Statistics Canada, 2006).

Low levels of physical activity reduce seniors' aerobic capacity and

strength, thereby lowering their functional independence and augmenting

disuse atrophy of their muscles, consequently elevating fall risk. This

relationship positively feeds back on the amount of exercise older adults