This study was funded by the Coordination for the Improvement of Higher Education Personnel of Brazil (CAPES- #1800789).

The study was approved by the Research Ethics Committee of the University of Campinas (UNICAMP) under Protocol Number 2479761. Written informed consent was obtained in-person from all study participants. Sixteen participants of both sexes were recruited from the community of the metropolitan region of Campinas by searching the database of the Applied Kinesiology Laboratory (AKL). The inclusion criteria were 1) individuals aged 60 and older; 2) ability to answer the questionnaires used in this study; 3) ability to walk independently without difficulty; 4) availability to participate in the intervention during 3 months with at least 90% attendance. The exclusion criteria were 1) severe cardiovascular or pulmonary diseases; 2) orthopedic diseases that prevented performing daily activities; and 3) diseases that increased the risk of falls such as Parkinson&#39;s and Alzheimer&#39;s. All assessments were performed by researchers and professional physical trainers from the AKL.
1. Assessment
<ol>
	<li>Assess physical fitness using the following functional tests: Illinois agility, five times sit-to-stand, timed up-and-go, walking usual speed, and one-leg stand. Perform all tests before and after training. 
	NOTE: Here, the participants repeated each test 2x, and the best result was used.
	<ol>
		<li>Illinois agility test: Have the participants move through obstacles in multiple directions.
		<ol>
			<li>The length of the course is 10 m and the width is 5 m. Place a marking cone in each corner of the course: a start and finish cone at one end, 5 m apart; two at the turning points on the other end of the course, 5 m apart; and four cones in the center of the course spaced 3.3 m apart from each other.</li>
			<li>Have the participants jog in a straight line from the start line to the first turning point and then in the opposite direction towards the first center cone. They should weave back and forth through the four center cones from one end of the course to the other. Then, they should run diagonally from the first center cone to the second turning point located on the far right and then in the opposite direction towards the finish line14.</li>
		</ol>
		</li>
		<li>Five times sit-to-stand test: Have the participants rise from a chair 5x as quickly as possible with the arms crossed in front of the body, lifting the hips from the chair when the timer is started. The participants should stand up completely by extending the knees and sit down completely by maintaining the back against the chair15. Stop the timer after the participant sits down for the fifth time.</li>
		<li>Timed up-and-go (TUG) test: Have the participants get up from a chair without pushing up with their arms, walk as quickly as possible along a 3 m line demarcated on the floor upon hearing the command &#34;Go,&#34; return to the same position, and sit down on the chair again. Timing starts as the participants get up from their chair and stopped when the participant sits down16.</li>
		<li>Walking usual speed test: Have the participants walk 10 m at their usual gait. Start the timer when a foot reaches the 1 m line and stop when a foot reaches the 11 m line. Do not include the first and last 1 m stretches in the analysis because they are used to measure acceleration and deceleration, respectively17. Present the results as velocity in m/s (Figure 2).</li>
		<li>One-leg stand test: Have the participants stand on the foot from the dominant leg while flexing the contralateral knee at 90&#176;, folding the arms across the chest, and maintaining the head straight. Have the participants lift one foot from the floor when the timer is activated. Stop the timer when the foot touches the floor again. The maximum balance time is 30 seconds for each side. Test both legs18.</li>
	</ol>
	</li>
</ol>
2. Training program design
<ol>
	<li>Have the participants perform agility training for 12 min, including four 3 min sets with a 1 min rest between each set (i.e., the first set starts with sequence 1). Each set is composed of four 30 s subsets, a 15 s rest between subsets (Figure 3), and 1 min rest between sets.
	<ol>
		<li>In addition to the four exercise sequences, include a 10 min warm-up and 5 min cool-down, using whole-body low-intensity stretching. 
		NOTE: During this program, each participant trained 2x per week for 14 weeks.</li>
	</ol>
	</li>
	<li>Increase the level of difficulty by augmenting exercise complexity and volume, depending on individual adaptation to the program. The level of adaptation dictates the level of increase in the velocity of the drills.
	<ol>
		<li>Increase training complexity after 6 weeks of training with four sequences of coordination. After a period of adaptation, substitute sequences 2 and 3 for more challenging drills.</li>
		<li>Increase the training time after 10 weeks of training. Start with 12 min of exercise (four 3 min sets) and end with 15 min (five 3 min sets). 
		NOTE: At the end of each 30 s subset, the time taken to perform the activity is recorded. This procedure allows comparison of the distance travelled by each participant during each session of the training program.</li>
	</ol>
	</li>
</ol>
3. Agility ladder
<ol>
	<li>Perform the exercises using a ladder with a length of 4.8 m and 12 transverse rungs forming 12 squares (areas delimited by the rungs) measuring 40 cm 40 cm (Figure 1). Instruct the study subjects to step in the squares and not on the rungs.</li>
</ol>
4. Familiarization period
<ol>
	<li>Perform four sequences of the training program (1, 2A, 3A, and 4) during the 2 week familiarization period. Exercise sessions were spaced at least 48 h apart, and there was no time limit to complete the sequences in each session. Instruct the participants to practice these sequences to perform as well as possible during the training period.</li>
</ol>
5. Training program
NOTE: All drills start with both feet together on the start line.
<ol>
	<li>Sequence 1: Have participants place their left foot in the first square, the right foot in the second square, and so forth (Figure 4). Each sequence should be performed in both directions on the ladder for 30 s.</li>
	<li>Sequence 2A: Have participants position their right foot in the first square, then position the toes of the left foot in the first square, move the left foot to the second square, place the toes of the right foot on the second square, and so on (Figure 5).</li>
	<li>Sequence 2B: Increase the level of difficulty depending on individual adaptation to sequence 2A (Figure 6) by having participants move through the ladder in small jumps, with toe-tapping movements.
	<ol>
		<li>Have participants jump to the first square with both feet together such that the sole of the right foot touches the ground while the toes of the left foot touch the ground.</li>
		<li>Then, have them jump to the second square with both feet together, ensuring that the sole of the left foot touches the ground while the toes of the right foot touch the ground.</li>
		<li>Have subjects repeat this sequence until the end of the ladder.</li>
	</ol>
	</li>
	<li>Sequence 3A: Have participants perform the drill with diagonal and lateral movements.
	<ol>
		<li>Have them place their left foot, followed by the right foot, outside the first square to the left.</li>
		<li>Then, have them put the right foot in the first square, followed by the left foot. They will then place the right foot outside the second square to the right, followed by the left foot.</li>
		<li>Have subjects continue this sequence until the end of the ladder (Figure 7).</li>
	</ol>
	</li>
	<li>Sequence 3B: Use this sequence to increase the difficulty level depending on individual adaptation to sequence 3A.
	<ol>
		<li>Have participants position their left foot outside the ladder next to the first square to the left, and then the right foot in the first square, followed by the left foot, maintaining both feet together. Then, they will put the right foot outside the second square to the right and then the left foot in the second square, followed by the right foot, keeping both feet together (Figure 8).</li>
	</ol>
	</li>
	<li>Sequence 4: Have participants place their right foot in the first square, the left foot outside the ladder to the left next to the rung separating the first and second squares, and the right foot outside the ladder across from the left foot.
	<ol>
		<li>Have participants put the left foot in the second square, the right foot outside the ladder to the right next to the rung separating the second and third squares, and the left foot outside the ladder opposite the right foot. Have the subjects follow this pattern until the end of the ladder (Figure 9).</li>
	</ol>
	</li>
</ol>

<ol><li>Álvarez-García, J., Durán-Sánchez, A., Del Río-Rama, M. C., García-Vélez, D. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Active+ageing%3A+Mapping+of+scientific+coverage%5BTitle%5D)+AND+%22International+Journal+of+Environmental+Research+and+Public+Health%22%5BJournal%5D)">Active ageing: Mapping of scientific coverage.</a> International Journal of Environmental Research and Public Health. 15 (12), E2727(2018).</li>
<li>Weil, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Aging+And+Health%5BTitle%5D)+AND+%22Health+Affairs%22%5BJournal%5D)">Aging And Health.</a> Health Affairs. 34 (1), 6(2018).</li>
<li>Sheppard, J., Young, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Agility+literature+review%3A+Classifications%2C+training+and+testing%5BTitle%5D)+AND+%22Journal+of+Sports+Sciences%22%5BJournal%5D)">Agility literature review: Classifications, training and testing.</a> Journal of Sports Sciences. 24 (9), 919-932 (2006).</li>
<li>Paul, D. J., Gabbett, T. J., Nassis, G. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Agility+in+Team+Sports%3A+Testing%2C+Training+and+Factors+Affecting+Performance%5BTitle%5D)+AND+%22Sports+Medicine%22%5BJournal%5D)">Agility in Team Sports: Testing, Training and Factors Affecting Performance.</a> Sports Medicine. 46 (3), 421-442 (2016).</li>
<li>Okubo, Y., Schoene, D., Lord, S. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Step+training+improves+reaction+time%2C+gait+and+balance+and+reduces+falls+in+older+people%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22British+Journal+of+Sports+Medicine%22%5BJournal%5D)">Step training improves reaction time, gait and balance and reduces falls in older people: A systematic review and meta-analysis.</a> British Journal of Sports Medicine. 51 (7), 586-593 (2017).</li>
<li>Liu-Ambrose, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Resistance+and+Agility+Training+Reduce+Fall+Risk+in+Women+Aged+75+to+85+with+Low+Bone+Mass%3A+A+6-Month+Randomized%2C+Controlled+Trial%5BTitle%5D)+AND+%22Journal+of+the+American+Geriatrics+Society%22%5BJournal%5D)">Resistance and Agility Training Reduce Fall Risk in Women Aged 75 to 85 with Low Bone Mass: A 6-Month Randomized, Controlled Trial.</a> Journal of the American Geriatrics Society. 52 (5), 657-665 (2004).</li>
<li>Liu-Ambrose, T., Khan, K. M., Eng, J. J., Lord, S. R., McKay, H. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Balance+confidence+improves+with+resistance+or+agility+training%3A+Increase+is+not+correlated+with+objective+changes+in+fall+risk+and+physical+abilities%5BTitle%5D)+AND+%22Gerontology%22%5BJournal%5D)">Balance confidence improves with resistance or agility training: Increase is not correlated with objective changes in fall risk and physical abilities.</a> Gerontology. 50 (6), 373-382 (2004).</li>
<li>Donath, L., van Dieën, J., Faude, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Exercise-Based+Fall+Prevention+in+the+Elderly%3A+What+About+Agility%3F%5BTitle%5D)+AND+%22Sports+Medicine%22%5BJournal%5D)">Exercise-Based Fall Prevention in the Elderly: What About Agility?</a> Sports Medicine. 46 (2), 143-149 (2016).</li>
<li>Diamond, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Executive+Functions%5BTitle%5D)+AND+%22Annual+Review+of+Clinical+Psychology%22%5BJournal%5D)">Executive Functions.</a> Annual Review of Clinical Psychology. 64 (1), 135-168 (2014).</li>
<li>Shigematsu, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Square-Stepping+Exercise+and+Fall+Risk+Factors+in+Older+Adults%3A+A+Single-Blind%2C+Randomized+Controlled+Trial%5BTitle%5D)+AND+%22Journals+of+Gerontology+Series+A+Biological+Sciences+%26+Medical+Sciences%22%5BJournal%5D)">Square-Stepping Exercise and Fall Risk Factors in Older Adults: A Single-Blind, Randomized Controlled Trial.</a> Journals of Gerontology Series A Biological Sciences & Medical Sciences. 63 (1), 76-82 (2008).</li>
<li>Teixeira, C. V. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+square-stepping+exercise+and+basic+exercises+on+functional+fitness+of+older+adults%5BTitle%5D)+AND+%22Geriatrics+and+Gerontology+International%22%5BJournal%5D)">Effect of square-stepping exercise and basic exercises on functional fitness of older adults.</a> Geriatrics and Gerontology International. 13 (4), 842-848 (2013).</li>
<li>Ng, R., Cheung, C. W., Kim Wai Sum, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effects+of+6-week+agility+ladder+drills+during+recess+intervention+on+dynamic+balance+performance%5BTitle%5D)+AND+%22Journal+of+Physical+Education+and+Sport%22%5BJournal%5D)">Effects of 6-week agility ladder drills during recess intervention on dynamic balance performance.</a> Journal of Physical Education and Sport. 17 (1), 306-311 (2017).</li>
<li>Pawar, S. B., Pradeep, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+ladder+drills+training+in+female+kabaddi+players%5BTitle%5D)+AND+%22International+Journal+of+Physical+Education%2C+Sports+and+Health%22%5BJournal%5D)">Effect of ladder drills training in female kabaddi players.</a> International Journal of Physical Education, Sports and Health. 180 (2), 180-184 (2018).</li>
<li>Raya, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparison+of+three+agility+tests+with+male+servicemembers%3A+Edgren+Side+Step+Test%2C+T-Test%2C+and+Illinois+Agility+Test%5BTitle%5D)+AND+%22Journal+of+Rehabilitation+Research+and+Development%22%5BJournal%5D)">Comparison of three agility tests with male servicemembers: Edgren Side Step Test, T-Test, and Illinois Agility Test.</a> Journal of Rehabilitation Research and Development. 50 (7), 951-960 (2013).</li>
<li>Buatois, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Five+times+sit+to+stand+test+is+a+predictor+of+recurrent+falls+in+healthy+community-living+subjects+aged+65+and+older%5BTitle%5D)+AND+%22Journal+of+the+American+Geriatrics+Society%22%5BJournal%5D)">Five times sit to stand test is a predictor of recurrent falls in healthy community-living subjects aged 65 and older.</a> Journal of the American Geriatrics Society. 56 (8), 1575-1577 (2008).</li>
<li>Podsiadlo, D., Richardson, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Timed+%22Up+%26+Go%22%3A+A+Test+of+Basic+Functional+Mobility+for+Frail+Elderly+Persons%5BTitle%5D)+AND+%22Journal+of+the+American+Geriatrics+Society%22%5BJournal%5D)">The Timed "Up & Go": A Test of Basic Functional Mobility for Frail Elderly Persons.</a> Journal of the American Geriatrics Society. 39 (2), 142-148 (1991).</li>
<li>Yamada, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Prevalence+of+sarcopenia+in+community-dwelling+Japanese+older+adults%5BTitle%5D)+AND+%22Journal+of+the+American+Medical+Directors+Association%22%5BJournal%5D)">Prevalence of sarcopenia in community-dwelling Japanese older adults.</a> Journal of the American Medical Directors Association. 14 (12), 911-915 (2013).</li>
<li>Briggs, R. C., Gossman, M. R., Birch, R., Drews, J. E., Shaddeau, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Balance+performance+among+noninstitutionalized+elderly+women%5BTitle%5D)+AND+%22Physical+Therapy%22%5BJournal%5D)">Balance performance among noninstitutionalized elderly women.</a> Physical Therapy. 69 (9), 748-756 (1989).</li>
<li>Yamada, M., Tanaka, B., Nagai, K., Aoyama, T., Ichihashi, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Rhythmic+stepping+exercise+under+cognitive+conditions+improves+fall+risk+factors+in+community-dwelling+older+adults%3A+Preliminary+results+of+a+cluster-randomized+controlled+trial%5BTitle%5D)+AND+%22Aging+%26+Mental+Health%22%5BJournal%5D)">Rhythmic stepping exercise under cognitive conditions improves fall risk factors in community-dwelling older adults: Preliminary results of a cluster-randomized controlled trial.</a> Aging & Mental Health. 15 (5), 647-653 (2011).</li>
<li>Reid, K. F., Fielding, R. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Skeletal+muscle+power%3A+A+critical+determinant+of+physical+functioning+in+older+adults%5BTitle%5D)+AND+%22Exercise+and+Sport+Sciences+Reviews%22%5BJournal%5D)">Skeletal muscle power: A critical determinant of physical functioning in older adults.</a> Exercise and Sport Sciences Reviews. 40 (1), 4-12 (2012).</li>
<li>Bouaziz, W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Health+benefits+of+multicomponent+training+programmes+in+seniors%3A+a+systematic+review%5BTitle%5D)+AND+%22International+Journal+of+Clinical+Practice%22%5BJournal%5D)">Health benefits of multicomponent training programmes in seniors: a systematic review.</a> International Journal of Clinical Practice. 70 (7), 520-536 (2016).</li>
</ol>

The authors have nothing to disclose.

Several agility training programs are used for different populations, including sports teams4, children12, and older people6,10. These programs include square stepping exercises10,11 like the sequences described in the present study and can significantly improve the overall physical fitness of older adults by decreasing the risk of falls, fractures, immobilizations, and dependence.
The training protocol presented in this study, with explanations about exercise drills and training volume and intensity, constitutes another approach to improve agility in older people. This protocol is cost-effective, practical, readily accessible, and easily adapted to specific populations by changing velocity and complexity19. Furthermore, this method improved physical fitness even in robust and healthy populations.
The literature stresses the importance of using power exercises for older people. Muscle power is decreased with advancing age20. Therefore, neuromuscular performance is reduced even in robust and healthy older adults. This study reports an alternative training method using an agility ladder to help improve or maintain muscle power. Furthermore, the outcomes can be compared with those of other training programs, such as square stepping, which present physical and cognitive benefits10. Older people can benefit from several stimuli from a single exercise8,10.
This type of training can be included in multicomponent exercise programs for older people and has been shown to improve muscle strength and power, physical endurance, flexibility, and balance21. Nonetheless, few studies have evaluated the benefits of agility training in multicomponent programs, and most of these programs do not contemplate agility training21. Nevertheless, agility training can be included in multicomponent training because it improves physical functioning in older adults5,10,11, as demonstrated in the present study.
Agility ladders are effective for health training in specific population groups (e.g., populations with mild cognitive impairment who had a stroke). Furthermore, the complexity of coordination in preplanned gait and reaction training improves executive function5,6,9,11.
The study population was robust, healthy, and physically active. Therefore, further studies are necessary to assess the potential benefits of this protocol in frail and inactive older people. The two main limitations of this study were the small sample size and the lack of a control group. For this reason, the present results were not compared with those of a group that did not receive the intervention or those in traditional strength or endurance training programs. Notwithstanding, the present exercise protocol significantly improved overall physical fitness in this population.

Being active while aging can optimize opportunities to improve physical, social, and mental health, enabling older people to participate actively in society1. Older adults should be payed attention to because of the consequences of aging2. People worldwide are living longer, and life expectancy is greater than 70 years for the first time in history. The number of individuals aged 60 years or older is increasing rapidly, and the health of these populations is usually poor. Aging impairs physical functions, mental capacity, and social interactions as a direct result of diseases or syndromes2.
Decrease in physical function may lead to falls, fractures, less access to health care, depression, and poor quality of life. Agility is crucial to prevent falls and maintain independence in older people. Sheppard and Young3 reported that agility involved &#34;whole-body movements in different directions in response to a stimulus.&#34;
Most studies evaluate agility in high-performance athletes4, although a few studies assess this parameter in older adults. Agility training for older people comprises preplanned gait adaptability training and reaction training (i.e., response to a signal)5. Liu-Ambrose et al.6,7 found that agility training improved postural stability, balance, and balance confidence, and decreased the risk of falls in older people. Moreover, this type of training is integrative and improves cognitive functions (e.g., perception, mental flexibility, and working memory) as well as neuromuscular and cardiovascular functions8,9.
Agility training is characterized by a set of exercise drills and can be automated. However, a physical trainer/instructor is necessary to create and teach the drills and indicate the right moment to increase the level of difficulty. Some studies found that step training improved physical fitness (e.g., balance, agility, lower limb strength and power, and decreased risk of falls) and cognitive function (e.g., choice stepping reaction time, inhibitory action, and executive function)5,10,11. The present study uses an agility ladder as a cost-effective instrument to assess the effects of preplanned gait training on the physical fitness of independent community-dwelling older adults.
The agility ladder used in the present study was previously employed to train school children and athletes12,13. The ladder had a length of 4.8 meters and 12 transverse rungs and was drawn on the floor using a 2 cm wide adhesive tape (Figure 1). Building a ladder on the floor avoided interruptions during training12 and decreased the risk of injuries. The study population was healthy, with a mean age of 66.9 &#177; 5.0 years, and lived independently in a community setting. The participants received 30 minute training sessions twice a week for 14 weeks.

<table><tbody><tr><td>Bluetooth speaker</td><td>JBL</td><td>-</td><td>Used to time all protocol and signal the 30 s of each subset</td></tr><tr><td>Chair</td><td>-</td><td>-</td><td>Used on assessments</td></tr><tr><td>Clipboard</td><td>Tilibra</td><td>-</td><td>Used to support documents</td></tr><tr><td>Crepe Tape of 2cm</td><td>Dexter</td><td>-</td><td>Used to create the agility ladder on the floor</td></tr><tr><td>Measuring Tape</td><td>Stakley</td><td>-</td><td>Used to measure assessments distance</td></tr><tr><td>Pen</td><td>Bic</td><td>-</td><td>Used to note data</td></tr><tr><td>Saucer Cone</td><td>Kipsta</td><td>-</td><td>Used on assessments</td></tr><tr><td>Stowatch</td><td>Vollo</td><td>-</td><td>Used to time assessments results</td></tr><tr><td>Sulfite Paper</td><td>Chamex</td><td>-</td><td>used to write all data</td></tr></tbody></table>

a training program using an agility ladder for community-dwelling older adults

Aging impairs physical and cognitive functions and limits daily activities. Agility training can improve or maintain physical functioning in older people. The purpose of this study is to report the physical fitness benefits of a training program for independent community-dwelling older adults using an agility ladder. Each training session lasted approximately 30 minutes, and the benefits were achieved with two sessions per week for 14 weeks. Training was timed and involved four different drills and varying levels of difficulty through time. The exercises were performed at the School of Physical Education of the University of Campinas, S&#227;o Paulo state, Brazil. The study participants (n = 16; mean age of 66.9 &#177; 5.0 years) were instructed to perform the exercises as quickly as possible without making mistakes and were assisted by a physical trainer when they made mistakes. Assessments were performed both before and after training using five functional tests (i.e., Illinois agility, five times sit-to-stand, timed up-and-go, walking usual speed, and one-leg stand). Although the study sample was not compared with a control group, the results indicate that training protocols using an agility ladder are easy and practical and improve physical function performance in older adults.

Sixteen male and female independent community-living older people with a mean age of 66.9 &#177; 5.0 years were enrolled in the study. The interventions and assessments were performed at the School of Physical Education of UNICAMP.
Statistical analysis was performed using Minitab 18 software. The Mann-Whitney test was used to compare the functional test results before and after training. P values smaller than 0.05 were considered significant. Delta was calculated as follows: (baseline values - post-training values) / baseline values x 100.
Significant differences between before and after training were determined using physical function tests to assess agility (Illinois test), lower limb strength and power (five times sit-to-stand), dynamic balance (TUG), gait (walking usual speed test), and static balance (one-leg stand).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/60468/60468fig1a.jpg" /> 
Figure 1: Agility ladder. The ladder had a length of 4.8 m and 12 rungs, forming 12 squares (40 cm x 40 cm). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig1alarge.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/60468/60468fig3.jpg" /> 
Figure 2: Walking usual speed test. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/60468/60468fig2.jpg" /> 
Figure 3: Exercise set. Each 3-min set was composed of four 30 s subsets and a 15 s rest between subsets. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/60468/60468fig4.jpg" /> 
Figure 4: Sequence 1. (A) the left foot in the first square, (B) the right foot in the second square, (C) the left foot in the third square. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/60468/60468fig5.jpg" /> 
Figure 5: Sequence 2A. (A) The right foot in the first square, (B) the left foot in the first square, (C) the left foot in the second square, (D) the right foot in the second square. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/60468/60468fig6.jpg" /> 
Figure 6: Sequence 2B. (A) The right foot in the first square and the toes of the left foot in the first square, (B) the left foot in the second square and the toes of the right foot in the second square, (C) the right foot in the third square and the toes of the left foot in the third square. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/60468/60468fig7.jpg" /> 
Figure 7: Sequence 3A. (A) The left foot outside the ladder to the left next to the first square, (B) the right foot outside the ladder next to the left foot, (C) the right foot in the first square, (D) the left foot in the first square, (E) the right foot outside the ladder to the right next to the first square, (F) the left foot next to the right foot. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig7large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 8" class="xfigimg" src="/files/ftp_upload/60468/60468fig8.jpg" /> 
Figure 8: Sequence 3B. (A) The left foot outside the ladder to the left next to the first square, (B) the right foot in the first square, (C) the left foot next to the right foot, (D) the right foot outside of the ladder to the right next to the first square, (E) the left foot next to the right foot. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig8large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 9" class="xfigimg" src="/files/ftp_upload/60468/60468fig9.jpg" /> 
Figure 9: Sequence 4. (A) The right foot in the first square, (B) the left foot outside the ladder to the left next to the rung that separates the first and second squares, (C) the right foot outside the ladder to the right across from the left foot, (D) the left foot in the second square, (E) the right foot outside the ladder to the right next to the rung that separates the second and third squares, (F) the left foot outside the ladder across from the right foot. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig9large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 10" class="xfigimg" src="/files/ftp_upload/60468/60468fig10.jpg" /> 
Figure 10: Delta values of the function test results. The percentage of training (delta) of each measurement was assessed over time. FTSS, five times sit-to-stand; WS, walking speed; TUG, timed up-and-go; OLS, one-leg stand using the right left (R) and left leg (L). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/60468/60468fig10large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Tests</td>
			<td>Pre</td>
			<td>Post</td>
			<td>P-Value</td>
		</tr>
		<tr>
			<td>Illinois (s)</td>
			<td>35.9 &#177; 5.4</td>
			<td>31.5 &#177; 4.5</td>
			<td>0.02*</td>
		</tr>
		<tr>
			<td>FTSS (s)</td>
			<td>10.7 &#177; 2.0</td>
			<td>7.7 &#177; 1,1</td>
			<td>&#60;0.01*</td>
		</tr>
		<tr>
			<td>TUG (s)</td>
			<td>7.7 &#177; 1.2</td>
			<td>5.8 &#177; 0.7</td>
			<td>&#60;0.01*</td>
		</tr>
		<tr>
			<td>WS (m/s)</td>
			<td>1.3 &#177; 0.1</td>
			<td>1.5 &#177; 0,1</td>
			<td>&#60;0.01*</td>
		</tr>
		<tr>
			<td>OLS R (s)</td>
			<td>16.4 &#177; 10.4</td>
			<td>23.7 &#177; 9.0</td>
			<td>0.03*</td>
		</tr>
		<tr>
			<td>OLS L (s)</td>
			<td>15.7 &#177; 8.5</td>
			<td>24.6 &#177; 8.1</td>
			<td>0.01*</td>
		</tr>
	</tbody>
</table>
Table 1: Functional test results at baseline and post-training. Data are presented as means &#177; standard deviations and were considered significantly different at p &#60; 0.05. *The Mann-Whitney test was used to compare differences between before and after training. FTSS, five times sit-to-stand; WS, walking speed; TUG, timed up-and-go; OLS, one-leg stand (OLS); R, right leg; L, left leg.

Watch this Scientific Journal Video about A Training Program Using an Agility Ladder for Community-Dwelling Older Adults at JoVE.com

A Training Program Using an Agility Ladder for Community-Dwelling Older Adults

The aim of this study is to present an agility training program for older people. The feasibility of this program is described, and the training protocol demonstrated by video imaging.

Aging impairs physical and cognitive functions and limits daily activities. Agility training can improve or maintain physical functioning in older people. ...

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Nanyang Technological University

Research

JoVE Journal

Medicine

10.3K Views.  University of Campinas, UNICAMP. The aim of this study is to present an agility training program for older people. The feasibility of this program is described, and the training protocol demonstrated by video imaging.

Video: A Training Program Using an Agility Ladder for Community-Dwelling Older Adults

Community-based Adapted Tango Dancing for Individuals with Parkinson's Disease and Older Adults

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple step elements. Adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics likely underlie adapted tango&#8217;s demonstrated efficacy for improving mobility and balance. In this paper, we describe the methodology to disseminate the adapted tango teaching methods to dance instructor trainees and to implement the adapted tango by the trainees in the community for older adults and individuals with Parkinson&#8217;s Disease (PD). Efficacy in improving mobility (measured with the Timed Up and Go, Tandem stance, Berg Balance Scale, Gait Speed and 30 sec chair stand), safety and fidelity of the program is maximized through targeted instructor and volunteer training and a structured detailed syllabus outlining class practices and progression.

Adapted tango has demonstrated efficacy for improving mobility and balance. We describe the dissemination of adapted tango teaching methods to dance instructor trainees and the implementation of adapted tango by the trainees in the community for improving mobility and balance in older adults and individuals with Parkinson&#8217;s disease.

Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple ...

Behavior

A Murine Model of Muscle Training by Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional capacity. Transcutaneous surface stimulation of skeletal muscle involves a current flow between a cathode and an anode, thereby inducing excitement of the motor unit and the surrounding muscle fibers. 
NMES is an attractive modality to evaluate skeletal muscle adaptive responses for several reasons. First, it provides a reproducible experimental model in which physiological adaptations, such as myofiber hypertophy and muscle strengthening6, angiogenesis7-9, growth factor secretion9-11, and muscle precursor cell activation12 are well documented. Such physiological responses may be carefully titrated using different parameters of stimulation (for Cochrane review, see 13). In addition, NMES recruits motor units non-selectively, and in a spatially fixed and temporally synchronous manner14, offering the advantage of exerting a treatment effect on all fibers, regardless of fiber type. Although there are specified contraindications to NMES in clinical populations, including peripheral venous disorders or malignancy, for example, NMES is safe and feasible, even for those who are ill and/or bedridden and for populations in which rigorous exercise may be challenging. 
Here, we demonstrate the protocol for adapting commercially available electrodes and performing a NMES protocol using a murine model. This animal model has the advantage of utilizing a clinically available device and providing instant feedback regarding positioning of the electrode to elicit the desired muscle contractile effect. For the purpose of this manuscript, we will describe the protocol for muscle stimulation of the anterior compartment muscles of a mouse hindlimb.

A murine model of neuromuscular electrical stimulation (NMES), a safe and inexpensive clinical modality, to the anterior compartment muscles is described. This model has the advantage of modifying a readily available clinical device for the purpose of eliciting targeted and specific muscle contractions in mice.

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional ...

Using Quantitative Real-time PCR to Determine Donor Cell Engraftment in a Competitive Murine Bone Marrow Transplantation Model

Murine bone marrow transplantation models provide an important tool in measuring hematopoietic stem cell (HSC) functions and determining genes/molecules that regulate HSCs. In these transplant model systems, the function of HSCs is determined by the ability of these cells to engraft and reconstitute lethally irradiated recipient mice. Commonly, the donor cell contribution/engraftment is measured by antibodies to donor- specific cell surface proteins using flow cytometry. However, this method heavily depends on the specificity and the ability of the cell surface marker to differentiate donor-derived cells from recipient-originated cells, which may not be available for all mouse strains. Considering the various backgrounds of genetically modified mouse strains in the market, this cell surface/ flow cytometry-based method has significant limitations especially in mouse strains that lack well-defined surface markers to separate donor cells from congenic recipient cells. Here, we reported a PCR-based technique to determine donor cell engraftment/contribution in transplant recipient mice. We transplanted male donor bone marrow HSCs to lethally irradiated congenic female mice. Peripheral blood samples were collected at different time points post transplantation. Bone marrow samples were obtained at the end of the experiments. Genomic DNA was isolated and the Y chromosome specific gene, Zfy1, was amplified using quantitative Real time PCR. The engraftment of male donor-derived cells in the female recipient mice was calculated against standard curve with known percentage of male vs. female DNAs. Bcl2 was used as a reference gene to normalize the total DNA amount. Our data suggested that this approach reliably determines donor cell engraftment and provides a useful, yet simple method in measuring hematopoietic cell reconstitution in murine bone marrow transplantation models. Our method can be routinely performed in most laboratories because no costly equipment such as flow cytometry is required.

Determining donor cell engraftment presents a challenge in mouse bone marrow transplant models that lack well-defined phenotypical markers. We described a methodology to quantify male donor cell engraftment in female transplant recipient mice. This method can be used in all mouse strains for the study of HSC functions.

Murine bone marrow transplantation models provide an important tool in measuring hematopoietic stem cell (HSC) functions and determining genes/molecules ...

The Ladder Rung Walking Task: A Scoring System and its Practical Application.

Progress in the development of animal models for/stroke, spinal cord injury, and other neurodegenerative disease requires tests of high sensitivity to elaborate distinct aspects of motor function and to determine even subtle loss of movement capacity. To enhance efficacy and resolution of testing, tests should permit qualitative and quantitative measures of motor function and be sensitive to changes in performance during recovery periods. The present study describes a new task to assess skilled walking in the rat to measure both forelimb and hindlimb function at the same time. Animals are required to walk along a horizontal ladder on which the spacing of the rungs is variable and is periodically changed. Changes in rung spacing prevent animals from learning the absolute and relative location of the rungs and so minimize the ability of the animals to compensate for impairments through learning. In addition, changing the spacing between the rungs allows the test to be used repeatedly in long-term studies. Methods are described for both quantitative and qualitative description of both fore- and hindlimb performance, including limb placing, stepping, co-ordination. Furthermore, use of compensatory strategies is indicated by missteps or compensatory steps in response to another limb&#x2019;s misplacement. 

The ladder rung walking task is a new test to assess skilled walking and measure both forelimb and hindlimb placing, stepping, and inter-limb co-ordination.

Progress in the development of animal models for/stroke, spinal cord injury, and other neurodegenerative disease requires tests of high sensitivity to ...

Biology

Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for wandering behaviors. The benefits of a RTLS are objective and continuous measurements of activity. Self-report methods of activity, especially wandering, by health care staff are vulnerable to floor effects and recall bias, and continuous clinical or research observation over the long-term can be time-consuming and expensive. Health care staff also fail to recognize the onset and/or duration of wandering behaviors, which are associated with a variety of adverse health outcomes in this population but amenable to intervention. RTLS technologies can measure the walking activity of institutionalized residents with cognitive impairment over time with a high degree of accuracy. This is particularly useful for the study of wandering, defined as walking for at least 60 seconds with few (if any) breaks in activity. Wandering is associated with disease progression, hospitalizations, falls and death. Previous work suggests older adults with poor balance ability and high sustained walking activity may be particularly susceptible to poor health outcomes. RTLS&#39;s are used to assess cognitive impairment and factors associated with gait and balance; however, supplemental paper and pencil gait/balance tools may be used to further refine risk profiles. This project discusses the use of a RTLS to measure walking activity and also gait quality and balance ability measures on this population.

This paper discusses the use of a continuous and objective real-time locating system to measure walking activity associated with wandering behaviors, focusing on older adults with cognitive impairment. Walking activity is measured by walking distance, sustained walking distance, and sustained gait speed. Also assessed are gait quality and balance ability.

A real-time locating system (RTLS) can be used to track the walking activity of institutionalized older adults in long-term care who are at risk for ...

Walk with Me Hybrid Virtual/In-Person Walking for Older Adults with Neurodegenerative Disease

This study presents a protocol for virtual and in-person walking groups for older adults with neurodegenerative diseases and addresses the decline in physical activity and social connectivity during the pandemic. Physical activity, specifically moderate-intensity walking, has been shown to have multiple health benefits for older adults. This methodology was created during the COVID-19 pandemic, contributing to lower physical activity levels and social isolation in older adults. Both the in-person and virtual classes utilize technology such as fitness tracking apps and video platforms. Data are presented from two groups of older adults with neurodegenerative disease: people with prodromal Alzheimer's disease and people with Parkinson's disease. Participants in the virtual classes were screened for balance impairments before the walk, and any person deemed at risk for falls was not eligible to participate virtually. As COVID vaccines became available and restrictions were lifted, in-person walking groups became feasible. Staff and caregivers were trained in balance management, roles/responsibilities, and delivering walking cues. Both walks, virtual and in-person, consisted of a warm up, a walk, and a cool down, and posture, gait, and safety cues were given throughout. Measures of the rate of perceived exertion (RPE) and heart rate (HR) were taken pre-warm up, post-warm up, and at 15 min, 30 min, and 45 min time points. Participants also used a walking application (app) on their phones to record the distance walked and the number of steps taken. The study showed a positive correlation between HR and RPE in both groups. The participants in the virtual group rated the walking group favorably in terms of improving their quality of life during a period of social isolation and contributing to physical, mental, and emotional well-being. The methodology shows a safe and feasible way to implement virtual and in-person walking groups for older adults with neurological diseases.

The present protocol aims to inform rehabilitation specialists and fitness instructors in safe, feasible, and evidence-based methods of delivering virtual and in-person walking classes to older adults with neurodegenerative diseases.

This study presents a protocol for virtual and in-person walking groups for older adults with neurodegenerative diseases and addresses the decline in ...

Assessing Motor Performance in TH-Related Murine Models Using the Ladder Beam Test

A Versatile, Behavioral Method to Investigate Thyroid Hormone Effects on Cerebellar Function

Thyroid hormone (TH) action is essential during the development of the central nervous system, including the cerebellum. In case of TH deficiency in early life such as congenital hypothyroidism, patients display neurological disorders such as cognitive retardation and motor deficits. There are various studies using mouse models with tissue- or cell-specific TH deficiency to investigate the role of TH in the cerebellum. Compared to generalized congenital hypothyroid mice, cerebellar cell-specific TH-deficient mice display milder and subtler ataxic features, making the assessment of motor function difficult when using conventional tests such as the rotarod test. 
Due to the need for an alternative tool to assess motor function in TH-related animal models, we developed a versatile behavioral method called the "ladder beam test," in which we can design the various ladder tests depending on the severity of ataxia in model mice. We utilized transgenic mice expressing a dominant-negative TH receptor specifically in the cerebellar Purkinje cell, a sole output neuron in the cerebellar cortex modulating motor performance. The newly-built ladder beam test successfully detected robust impairments in motor performance in the transgenic mice at a greater level compared to the rotarod test. Disruption of motor learning was also detected in the ladder beam test but not in the rotarod test. The protocol with this novel behavioral apparatus can be applied to other animal models that may show mild ataxic phenotype to examine subtle changes in cerebellar function.

Author Spotlight: Accurately Assessing Thyroid Hormone-Driven Motor Alterations in Mouse

Here we present a protocol for a versatile behavior test developed recently, the ladder beam test. This test has the advantage of detecting subtle cerebellar ataxia caused by a defect of thyroid hormone action in the central nervous system over the conventional behavior tests assessing motor performance.

Thyroid hormone (TH) action is essential during the development of the central nervous system, including the cerebellum. In case of TH deficiency in early ...

Adapted Resistance Training Improves Strength in Eight Weeks in Individuals with Multiple Sclerosis

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can improve strength in individuals with MS, however; it remains unclear the duration of RST that is needed to make strength gains and how to adapt hip strengthening exercises for individuals of varying strength using only resistance bands. This paper describes the methodology to set up and implement an adapted resistance strength training program, using resistance bands, for individuals with MS. Directions for pre- and post-strength tests to evaluate efficacy of the strength-training program are included. Safety features and detailed instructions outline the weekly program content and progression. Current evidence is presented showing that significant strength gains can be made within 8 weeks of starting a RST program. Evidence is also presented showing that resistance strength training can be successfully adapted for individuals with MS of varying strength with little equipment.

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis. Isolated muscle strengthening is a useful method to target specific weaknesses. This protocol describes a progressive resistance-training program using exercise bands to increase hip muscle strength.

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can ...

Exergaming in Older People Living with HIV Improves Balance, Mobility and Ameliorates Some Aspects of Frailty

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is aging. HIV-positive individuals have a high incidence of frailty (~20%) characterized by depression and sedentary behavior. Exercise would be healthy, but due to the frail status of many HIV-positive individuals, conventional exercise is too taxing. The aim of this study was to evaluate the effectiveness and acceptability of a novel game-based training program (exergame) in ameliorating some aspects of frailty in HIV-infected individuals. Ten older people living with HIV were enrolled in an exergame intervention. Patients performed balance exercises such as weight shifting, ankle reaching, and obstacle crossing. Real-time visual/audio lower-extremity joint motion feedback was provided using wearable sensors to assist feedback and encourage subjects to accurately execute each exercise task. Patients trained twice a week for 45 min for 6 weeks. Changes in balance, gait, psychosocial parameters and quality of life parameters were assessed at the beginning, midterm and at conclusion of the training program. Ten patients completed the study and their results analyzed. The mean age was 57.2 &#177; 9.2 years. The participants showed a significant reduction in center of mass sway (78.2%, p = .045) during the semi-tandem balance stance with eyes closed and showed a significant increase in gait speed during a dual task motor-cognitive assessment (9.3%, p = .048) with an increase in stride velocity of over 0.1 m/sec. A significant reduction in reported pain occurred (43.5%, p = .041). Preliminary results of this exergame intervention show promise in improving balance and mobility while requiring older people living with HIV to be more active. The exergame can be continued at home and may have long term as well as short-term benefits for ameliorating frailty associated with HIV infection.

Persons infected with HIV are often frail, depressed and live a sedentary lifestyle for which conventional exercise is too taxing. Here, we present an exercise protocol that ameliorates aspects of frailty in HIV-infected persons. An exergame integrating cognitive control was developed using biosensors that measured balance, weight-shifting and obstacle crossing.

Approximately 1.2 million people in the United States live with HIV infection. Medical advancements have increased the life expectancy and this cohort is ...

Versatility of Protocols for Resistance Training and Assessment Using Static and Dynamic Ladders in Animal Models

Resistance training is a physical exercise model with profound benefits for health throughout life. The use of resistance exercise animal models is a way to gain insight into the underlying molecular mechanisms that orchestrate these adaptations. The aim of this article is to describe exercise models and training protocols designed for strength training and evaluation of resistance in animal models and provide examples. In this article, strength training and resistance evaluation are based on ladder climbing activity, using static and dynamic ladders. These devices allow a variety of training models as well as provide precise control of the main variables which determine resistance exercise: volume, load, velocity, and frequency. Furthermore, unlike resistance exercise in humans, this is a forced exercise. Thus, aversive stimuli must be avoided in this intervention to preserve animal welfare. Prior to implementation, a detailed design is necessary, along with an acclimatization and learning period. Acclimatization to training devices, such as ladders, weights, and clinical tape, as well as to the manipulations required, is necessary to avoid exercise rejection and to minimize stress. At the same time, the animals are taught to climb up the ladder, not down, to the resting area on the top of the ladder. Resistance evaluation can characterize physical strength and permit adjusting and quantifying the training load and the response to training. Furthermore, different types of strength can be evaluated. Regarding training programs, with appropriate design and device use, they can be sufficiently versatile to modulate different types of strength. Furthermore, they should be flexible enough to be modified depending on the adaptive and behavioral response of the animals or the presence of injuries. In conclusion, resistance training and assessment using ladders and weights are versatile methods in animal research.

The present protocol describes resistance training and testing using static and dynamic ladders in animal models.

Resistance training is a physical exercise model with profound benefits for health throughout life. The use of resistance exercise animal models is a way ...