Virtual-reality Based Cognitive-motor-balance (VR-CogMoBal) Training: Examining Behavioral and Neuromarkers for Fall-risk Reduction in Older Adults With Mild Cognitive Impairment
Phase: NA
Conditions: Mild Cognitive Impairment
Sponsor: University of Illinois at Chicago

Virtual-reality based Cognitive-motor-balance (VR-CogMoBal) training: Examining 
behavioral and neuromarkers for fall-risk reduction in older adults with mild 
cognitive impairment (MCI) 
 
 
 
 
Principal Investigator: 
Tanvi Bhatt, PhD, Department of Physical Therapy, 
Room 729, AHSB, 1919 W. Taylor St., M/C 898 
University of Illinois, Chicago, 60612. 
(312) 355-4443 
NCT03765398 
 
Study Location(s): Rooms 415, 725, B-56, Department of Physical Therapy,  
AHSB, 1919 W. Taylor St., University of Illinois, Chicago, 60612   
 
Sponsor: Midwest Roybal Center for Health Promotion and Translation 
National Institutes of Health/NIA ADRD Supplement 
 
 
 
 
 

Methods 
Participants 
Older adults (> 55 years) will be recruited from the University of Illinois Hospital Geriatric 
Clinic and flyers in nearby independent living senior centers and grocery stores. We expect ten 
older adults participated in the study after obtaining a written informed consent. 
 
Participants’ eligibility 
To be included, participants must score 18-24 out of 30 on the Montreal Assessment on 
Cognitive Assessment (MoCA). Participants with uncontrolled cardiovascular disease, presence 
of any neurological condition (e.g., Alzheimer’s disease), and/or severe musculoskeletal diseases 
that may interfere with the ability to receive the intervention were excluded. Additionally, people 
with the inability to stand independently without an assistive device for the length of a Wii-Fit 
game, with a fracture risk heel bone density (measured using Lunar Achilles Insight) T-score < -
2.0, and inability to communicate and understand English were excluded. 
 
Research Design 
This study will be a single arm pre-post research design consisting of 4 weeks of DT exergaming 
sessions. Baseline (at week 0) and post-testing (at 5th week) outcome measures will be collected. 
 
Intervention 
In total, 12 sessions of individual one-on-one DT exergaming will be administered and 
supervised by a research personnel (physical therapist) in a research facility. Participants will 
wear a gait belt and were supervised during the session. DT exergaming will be delivered via 
Wii-Fit standing balance games which was performed at light intensity (rate of perceived 
exertion via Borg’s scale with individuals reporting score of 7-11) (17) and will be concurrently 
performed with explicit cognitive games (therapist cued) for 90 minutes/session, 3 times/ week. 
While Wii fit games will implicitly address cognitive domains like working memory, episodic 
memory, and visuospatial awareness, explicit cognitive games targeted subdomains of executive 
function – working memory and attention, and semantic memory, abstract memory. Warm up 
(step-in-place, trunk twists) and cool down (stretching of lower limb) will be performed before 
and after session, respectively. Refer to supplementary material section for details of protocol. 
 

Assessments 
Volitional balance control task: The limits of stability (LOS) test via Balance Master (Equitest® 
Neurocom) (18) will be administered. Participants will be secured in a safety harness and asked 
to stand on the force platform of the Balance Master (Figure 1). Participants will be instructed to 
lean their body either in the forward, backward, left, or right direction to move their center of 
gravity (COG) projection shown on a screen to the desired direction without losing balance, 
stepping, or reaching for assistance. 
 
 
 
Figure 1 
Represents a picture of an individual performing the limits of stability test on Balance Master 
(Equitest® Neurocom) in the forward direction 
 
Cognitive task 
Auditory clock test (ACT) (19) and letter number sequencing task (LNS) (20) will be 
administered using the DirectRT EmpirisoftTM (21) software to assess subdomains of executive 
function (visuo-spatial memory, working memory, attention, and cognitive flexibility). The audio 

cues will be delivered through headphones and responses will be recorded through a microphone. 
The ACT involves responding to different times of the day, “yes” if the hour and the minute 
hand was on the same side of the clock face and “no” otherwise. The LNS will involve 
sequentially listing alternate letter and number combinations, for example, response to “C5,” was 
D6, E7, etc. 
 
Interference test 
The LOS test (all directions) will be performed along with both cognitive tasks mentioned above. 
Participants will began responding to the cognitive cues followed by the LOS task. 
 
NIH Toolbox 
An iPad will be used to test the motor and cognitive domains. The motor tests will include 4-
meter gait speed test and 2-minute walk test. The cognitive tests include list sort memory test 
(working memory), picture sequence memory test (episodic memory), dimensional change card 
sort test (executive function), flanker inhibitory control and attention test (attention and 
executive function), and pattern comparison processing speed test (processing speed) (refer 
supplementary material section). 
 
Outcome measures 
Volitional balance control and interference task: Single task (task when performed alone) and 
performance during interference task was quantified by the movement stability measurement of 
maximum excursion (MXE, expressed in percentage), which is the maximum ability to shift 
one’s COG toward the theoretical limit in the desired direction. Higher values indicate better 
performance. 
Cognitive and interference task: Accuracy [(Correct responses)(Total responses)*100] was 
calculated during single and interference task. 
NIH toolbox: Speed (m/sec) for 4-meter gait test and distance covered in 2-minute walk test for 
endurance will be computed. Number of correct responses for list sort memory test and accuracy 
for the remainder tests was included for analysis. 
 

 
Statistical analyses 
Statistical analyses will be performed using SPSS version 24, Chicago, IL, USA. For MXE in 
each volitional balance control task direction (i.e., forward, backward, left, and right), 2 x 2 
repeated measures analysis of variance (ANOVA) will be performed to examine the time (pre- to 
post-training) and task (single vs. interference task) differences on with follow-up post-hoc tests. 
Similarly, four repeated measures ANOVA for accuracy (cognitive) in ACT and LNS will be 
performed. Paired t-test will be conducted for NIH toolbox measures. Refer supplementary 
material section for detail