The SaVe project - Sarcopenia and Vertigo in aging patients with colorectal cancer: A study protocol for three randomized controlled trials

INTRODUCTION

Older patients with cancer range from fit to frail with various comorbidities and resilience to chemotherapy. Besides nausea and fatigue, a significant number of patients experience dizziness and impaired walking balance after chemotherapy, which can have great impact on their functional ability and health related quality of life. Symptoms are easily overlooked and therefore often underreported and managed, which is why symptoms could end up as long-lasting side effects. The aim of this study is to investigate the development of dizziness, decline in walking balance, and sarcopenia and the effect of a comprehensive geriatric assessment and 12 weeks of group-based exercise on these symptoms. The exercise intervention includes vestibular and balance exercises, and progressive resistance training, to counteract the symptoms in older patients with colorectal cancer treated with chemotherapy.

MATERIALS AND METHODS

This is a randomized controlled trial including patients ≥65 years initiating (neo)adjuvant or first-line palliative chemotherapy for colorectal cancer. Patients will undergo a comprehensive assessment program including measures of vestibular function, balance, muscle strength, mass, and endurance, peripheral and autonomic nerve function, and subjective measures of dizziness, concern of falling, and health related quality of life. Tests will be performed at baseline, 12, and 24 weeks. Patients will be placed in three different randomized controlled trials depending on chemotherapy regimen and randomized 1:1 to comprehensive geriatric assessment and exercise three times/week or control. Participants in both groups will continue with usual care, including standardized oncological treatment. In total, 150 patients are needed to assess the two primary outcomes of (1) maintenance of walking balance assessed with Dynamic Gait Index and (2) lower limb strength and endurance assessed with 30 Second Sit-to-Stand Test at 12 weeks. The primary outcomes will be analyzed using a mixed linear regression model investigating the between-group differences.

DISCUSSION

Trial enrollment began in April 2023 and is the first trial to evaluate reasons for dizziness, decline in walking balance, and sarcopenia in older patients receiving chemotherapy. The trial will provide new and valuable knowledge in how to assess, manage, and prevent dizziness, decline in walking balance, and sarcopenia in older patients with colorectal cancer.

TRIAL REGISTRATION

The Regional Ethics Committee (j.nr. H-22064206). Danish Data Protection Agency (P-2023-86) and ClinicalTrials.gov (NCT05710809).

Effects of Motor-Cognitive Dual-Task Standing Balance Exergaming Training on Healthy Older Adults' Standing Balance and Walking Performance

Objective: This study examined the effects of motor-cognitive dual-task exergaming standing balance training on healthy older adults' static, dynamic, and walking balance. Methods: Twenty-four adults older than 70 years (control group: n = 9, males = 6, balance training group: n = 15, males = 8) completed the experiment. Dual-tasking standing balance training comprised the accurate control of a ping-pong ball on a tray held with both hands, while standing on one leg (analog training) and three modules of Wii Fit™ exergaming (digital training). The duration of balance training was ∼15 minutes per day, 2 days per week for 8 weeks, in total 16 sessions. We measured one-leg standing time, functional reach distance, walking balance evaluated by the distance walked on a narrow beam (4-cm long, 4-cm wide, and 2-cm high) with single and dual tasking, habitual and maximal walking speed, and muscle strength of the hip extensor, hip abductor, hip adductor, knee extensor, and plantarflexor muscle groups in the right leg at baseline and after 8 weeks. Results: Control group decreased, but balance training group increased one-leg standing time. Only the balance training group improved functional reach distance and hip and knee extensor strength. There was no change in walking speed and walking balance in either group. In the balance training group, changes in maximal speed correlated with changes in dual-tasking walking balance and changes in one-leg standing time correlated with changes in single-tasking walking balance. Conclusion: These results suggest that 16 sessions of motor-cognitive dual-task standing exergaming balance training substantially improved healthy older adults' static and dynamic balance and leg muscle strength but failed to improve walking speed and walking balance. Balance exercises specific to walking balance need to be included in balance training to improve walking balance.

Worse balance is associated with larger perturbation-evoked cortical responses in healthy young adults

BACKGROUND

Reactive balance recovery evokes a negative peak of cortical electroencephalography (EEG) activity (N1) that is simultaneous to brainstem-mediated automatic balance-correcting muscle activity. This study follows up on an observation from a previous study, in which N1 responses were larger in individuals who seemed to have greater difficulty responding to support-surface perturbations.

RESEARCH QUESTION

We hypothesized that people engage more cortical activity when balance recovery is more challenging. We predicted that people with lower balance ability would exhibit larger cortical N1 responses during balance perturbations.

METHODS

In 20 healthy young adults (11 female, ages 19-38) we measured the amplitude of the cortical N1 response evoked by 48 backward translational support-surface perturbations of unpredictable timing and amplitude. Perturbations included a Small (8 cm) perturbation that was identical across participants, as well as Medium (13-15 cm) and Large (18-22 cm) perturbations scaled to participant height to control for height-related differences in perturbation difficulty. To assess individual differences in balance ability, we measured the distance traversed on a narrow (0.5-inch wide) 12-foot beam across 6 trials. We tested whether the cortical N1 response amplitude was correlated to balance ability across participants.

RESULTS

Cortical N1 amplitudes in response to standing balance perturbations (54 ± 18 μV) were inversely correlated to the distance traveled in the difficult beam-walking task (R² = 0.20, p = 0.029). Further, there was a significant interaction between performance on the beam-walking task and the effect of perturbation magnitude on the cortical N1 response amplitude, whereby individuals who performed worse on the beam-walking task had greater increases in N1 amplitudes with increases in perturbation magnitude.

SIGNIFICANCE

Cortical N1 response amplitudes may reflect greater cortical involvement in balance recovery when challenged. This increased cortical involvement may reflect cognitive processes such as greater perceived threat or attention to balance, which have the potential to influence subsequent motor control.

Visually fixating or tracking another person decreases balance control in young and older females walking in a real-world scenario

Balance control during overground walking was assessed in 10 young (23.6 ± 3.4) and 10 older (71.0 ± 5.5 years) healthy females during free gaze, and when fixating or tracking another person in an everyday use waiting room. Balance control was characterised by medial/lateral sacrum acceleration dispersion, and gaze fixations were simultaneously assessed with eye tracking equipment. The results showed decreased balance control when fixating a stationary (p = 0.003, g_av = 0.19) and tracking a walking (p = 0.027, g_av = 0.16) person compared to free gaze. The older adults exhibited reduced baseline stability throughout, but the decrease caused by the visual tasks was not more profound than the younger adults. The decreased balance control when fixating on or tracking the observed person was likely due to more challenging conditions for interpreting retinal flow, which facilitated less reliable estimates of self-motion through vision. The older adults either processed retinal flow during the tasks as effectively as the young adults, or they adopted a more rigid posture to facilitate visual stability, which masked any ageing effect of the visual tasks. The decrease in balance control, the first to be shown in this context, may warrant further investigation in those with ocular or vestibular dysfunction.

Walking balance is mediated by muscle strength and bone mineral density in postmenopausal women: an observational study

BACKGROUND

Depletion of ovarian hormone in postmenopausal women has been associated with changes in the locomotor apparatus that may compromise walking function including muscle atrophy/weakness, weight gain, and bone demineralization. Therefore, handgrip strength (HGS), bone mineral density (BMD) and body composition [percentage body fat mass (%BFM), fat mass (FM), Fat-free mass (FFM) and body mass index (BMI)], may significantly vary and predict WB in postmenopausal women. Consequently, the study sought to 1. Explore body composition, BMD and muscle strength differences between premenopausal and postmenopausal women and 2. Explore how these variables [I.e., body composition, BMD and muscle strength] relate to WB in postmenopausal women.

METHOD

Fifty-one pre-menopausal (35.74 + 1.52) and 50 postmenopausal (53.32 + 2.28) women were selected by convenience sampling and studied. Six explanatory variables (HGS, BMD, %BFM, FFM, BMI and FM) were explored to predict WB in postmenopausal women: Data collected were analyzed using multiple linear regression, ANCOVA, independent t-test and Pearson correlation coefficient at p < 0.05.

RESULT

Postmenopausal women had higher BMI(t = + 1.72; p = 0.04), %BFM(t = + 2.77; p = .003), FM(t = + 1.77; p = 0.04) and lower HGS(t = - 3.05; p = 0.001),compared to the premenopausal women. The predicted main effect of age on HGS was not significant, F(1, 197) = 0.03, p = 0.06, likewise the interaction between age and %BFM, F(1, 197) = 0.02, p = 0.89; unlike the predicted main effect of %BFM, F(1, 197) = 10.34, p = .002, on HGS. HGS was the highest predictor of WB (t = 2.203; β=0.3046) in postmenopausal women and combined with T-score right big toe (Tscorert) to produce R² = 0.11;F (2, 47)=4.11;p = 0.02 as the best fit for the predictive model. The variance (R²) change was significant from HGS model (R² = 0.09;p = 0.03) to HGS + Tscorert model (R² = 0.11;p = 0.02). The regression model equation was therefore given as: WB =5.4805 + 0.1578(HGS) + (- 1.3532) Tscorert.

CONCLUSION

There are differences in body composition suggesting re-compartmentalization of the body, which may adversely impact the (HGS) muscle strength in postmenopausal women. Muscle strength and BMD are associated with WB, although, only contribute to a marginal amount of the variance for WB. Therefore, other factors in addition to musculoskeletal health are necessary to mitigate fall risk in postmenopausal women.

Ambulatory assessment of walking balance after stroke using instrumented shoes

BACKGROUND

For optimal guidance of walking rehabilitation therapy of stroke patients in an in-home setting, a small and easy to use wearable system is needed. In this paper we present a new shoe-integrated system that quantifies walking balance during activities of daily living and is not restricted to a lab environment. Quantitative parameters were related to clinically assessed level of balance in order to assess the additional information they provide.

METHODS

Data of 13 participants who suffered a stroke were recorded while walking 10 meter trials and wearing special instrumented shoes. The data from 3D force and torque sensors, 3D inertial sensors and ultrasound transducers were fused to estimate 3D (relative) position, velocity, orientation and ground reaction force of each foot. From these estimates, center of mass and base of support were derived together with a dynamic stability margin, which is the (velocity) extrapolated center of mass with respect to the front-line of the base of support in walking direction. Additionally, for each participant step lengths and stance times for both sides as well as asymmetries of these parameters were derived.

RESULTS

Using the proposed shoe-integrated system, a complete reconstruction of the kinematics and kinetics of both feet during walking can be made. Dynamic stability margin and step length symmetry were not significantly correlated with Berg Balance Scale (BBS) score, but participants with a BBS score below 45 showed a small-positive dynamic stability margin and more asymmetrical step lengths. More affected participants, having a lower BBS score, have a lower walking speed, make smaller steps, longer stance times and have more asymmetrical stance times.

CONCLUSIONS

The proposed shoe-integrated system and data analysis methods can be used to quantify daily-life walking performance and walking balance, in an ambulatory setting without the use of a lab restricted system. The presented system provides additional insight about the balance mechanism, via parameters describing walking patterns of an individual subject. This information can be used for patient specific and objective evaluation of walking balance and a better guidance of therapies during the rehabilitation.

TRIAL REGISTRATION

The study protocol is a subset of a larger protocol and registered in the Netherlands Trial Registry, number NTR3636 .

Effect of multifocal lens glasses on the stepping patterns of novice wearers

Multifocal lens glasses (MfLs) negatively affect vision, increase falling risk and contribute to gait changes during stepping. Previous studies on the effects of MfLs on gait have focused on experienced wearers. Thus, the initial response of first-time wearers, who may face significant challenges in adapting to these glasses, is not well understood. This study aimed to quantify the effects of MfLs on novice wearers during stepping up and down. Additionally, young adults were compared against a middle-aged adults to determine the validity of convenience sampling in testing novice response to MfLs. Fifteen young adults (18-34 y.o.) and seven middle-aged adults (46-56 y.o.) were recruited to perform stepping trials while wearing progressive MfLs and blank single lens glasses. Participants stepped up and down from a 75 mm and 150 mm step in randomized order. Step placement, minimum toe clearance, lower body kinematics and stepping time were measured during step up. Step placement, minimum heel clearance, vertical forces and stepping time were measured during step down. MfLs significantly increased toe clearance in the lead and trailing legs, hip flexion, knee flexion and stepping time during step up and increased vertical forces and stepping time during step down. Step placement and hip angle explained 17% of the toe clearance variability. Changes during step up suggest a more conservative adaptation while increased forces during step down suggest a reduced level of control. No age group effects were observed, which supports the use of convenience sampling for evaluating the novice response to MfLs.