Gait speed and cognition are important predictors of successful aging. Both slow gait speed and cognitive decline are associated with poor health outcomes, including hospitalization, falls, institutionalization and death. Exercise interventions can improve both gait and cognitive performance in older adults. Together in its entirety, the purpose of this dissertation was to examine the influence of a 12-week golf intervention on walking performance and cognition in older adults. Golf training, as a multimodal, cognitively-demanding physical activity, may have pronounced effects on walking ability and cognition. In the past, studies investigating golf have typically examined the performance of golfers (fitness, golf swing velocity, ball velocity, upper and lower-body mechanics during the golf swing) and few have examined the overall functional and health benefits that come from playing golf (see Chap. III). It is for this reason that we developed an intervention to safely and effectively teach older adults to become independent golfers via a 12-week golf training program, which may be an exercise modality that has pronounced effects on gait and cognition.

Although golfing is commonly viewed as a “recreational activity” and not “exercise”, recent reports suggest that the physical demands of golf (e.g. navigating the course, walking hilly terrain, bending over, swinging, weight-shifting) maintain/increase strength, flexibility, powerproduction, balance, and aerobic fitness in older adults. Moreover, golf is cognitively demanding, as evidenced by the preparation, strategizing, measuring, and execution phases of the game.

The Golf Intervention for Veterans Exercise (GIVE) study was a Phase I, 12-week golf training intervention study. All participants came to the USC Jacqueline Perry Musculoskeletal Biomechanics Research Laboratory for baseline testing within 2 weeks of the start of the 12- week intervention and returned to the lab within two weeks of the completion of the intervention for follow-up testing. Those in the intervention group (INT) participated in a 12-week golf training program (2 x weekly;​ 90 min per session) with a Professional Golf Association instructor. There was high adherence to the golf intervention (91%, average:​ 21.8/24 sessions attended), none of the participants dropped out the intervention, and there were no study-related adverse events. The control (CON) group continued to live “life-as-usual”. All participants completed a six-minute walk test (6MWT), fast single-task gait speed (STGS), fast dual-task gait speed (DTGS) with a subtraction by 3s task, California Verbal Learning Test 2nd edition (CVLTII) and National Institute Health Toolbox-Cognition (NIH-C) Battery.

Chapter III is an extensive literature review discussing the latest research examining multimodal, multicomponent, and cognitively-demanding physical activity interventions that have assessed gait and/or cognition in older adults with and without physical or cognitive impairments. Evidence is provided to support the argument that interventions that combine both physical and cognitive components have added benefits over interventions that only include a single-type (physical or cognitive) intervention.

The objective of Chapter IV was to answer the research question:​ Can a 12-week golf training program improve gait performance, and alter hip joint kinetics in older military Veterans? Twelve male military Veterans (60-80 years;​ average:​ 70.4 ± 4.8yrs) were enrolled in the GIVE study and completed the intervention. Pre- to post-intervention changes in gait, including six-minute walk test, single-task fast gait speed, stride length, cadence, sagittal plane hip joint kinetics were measured. Golf training significantly increased average fast gait speed (6.7%), stride length (4%), peak hip extensor moment (16.5%) and peak power generation (46.5%). The 12-week golf training program increased fast gait performance in older military Veterans, as well as increased hip joint kinetics. These changes are likely related to the physical demands of the 12-week golf program, which included walking the golf course, high-powered swings and bending/squatting activities.

The purpose of Chapter V was to compare changes in dual-task (DT) gait performance (maximal/fast gait speed, stride length, cadence), DT cost percentage, episodic memory and fluid cognition between individuals (n=12) who participated in a 12-week golf training intervention (INT;​ 90 min, 2x/week ) and an age-, education- and activity-matched control (CON) group (n=10). This study was a quasi-experimental design in which participants were not randomly assigned to groups.

DT performance is often used to examine the relations among mobility, cognition, and aging, and poor DT performance is associated with increased fall risk and dementia in older adults. Because golf training requires both physical and cognitive demands to be performed simultaneously, it was hypothesized that the INT group would demonstrate significantly greater pre-to-post improvements in DT gait and cognitive performance compared to the CON group. Two-factor mixed-model ANOVA revealed significant interactions between group and time for DT gait speed and long-delay episodic memory, and approached significance for DT stride length, and fluid cognition. Post-hoc paired t-tests revealed significant pre-to-post (p<0.05) improvements for DT fast gait speed (9.8%), DT stride length (4.3%), long-delay episodic memory (45.8%), and fluid cognition (15.3%). There were no pre-to-post changes in the CON group. The effect sizes for above variables were large (η²=0.18-0.31), suggesting that there was a golf training effect on DT gait and cognitive performance. The combined demands of golf, with their effects on neuroplasticity, may be the drivers behind the improvements demonstrated by the intervention group. This study’s results are supported by existing evidence suggesting that simultaneous physical and cognitive training may be more beneficial in improving DT performance and cognitive function than physical or cognitive training alone. These findings indicate that participation in a 12-week golf training program improves DT gait and cognitive performance in older adults and that golf may be considered a multimodal, cognitively-demanding physical activity.

These studies demonstrate that participation in a 12-week golf training program golf is safe, feasible, and effective in improving gait and cognitive performance in older adults. While there were limitations such as a non-randomized control group and small sample size, the large effect sizes observed, along with significant improvements in our intervention participants, reflect meaningful changes that attest to the overall health benefits of golf training. The high adherence level (91%) gives us insight into how our participants valued and enjoyed the intervention. These results provide evidence that golf, as a multimodal, cognitively-demanding physical activity, may improve physical and cognitive function, leading to attenuated risk for poor health outcomes, maintained independence and improved quality of life.