Motor Imagery and Turning Practice to Improve Mobility: Pilot Trial

This randomized pilot clinical trial will evaluate the feasibility and preliminary efficacy of combining in-person locomotor turning practice with home-based Motor Imagery Therapy (MIT) in older adults with self-reported balance or turning-related mobility concerns. Turning is a common component of daily mobility and a frequent contributor to falls in older adults, yet it is often underemphasized in traditional rehabilitation programs. MIT is a non-invasive behavioral approach that combines mental rehearsal of movement with action observation to engage brain networks involved in movement planning and motor learning.

Thirty community-dwelling older adults aged 65 years and older will be randomized to either a locomotor turning intervention combined with MIT (Loco+MIT) or a locomotor turning intervention combined with stress management education (Loco+SME). Both groups will complete six weeks of in-person turning practice focused on dynamic turning, weight shifting, and head-trunk coordination. Home-based sessions will be completed on alternating days and will consist of either guided motor imagery and action observation exercises or stress management and wellness education without motor practice components.

The study will evaluate feasibility outcomes including intervention attendance, participant retention, and compliance with remote activity monitoring. Preliminary efficacy outcomes will include turning performance, free-living physical activity, walking intensity, sedentary behavior, and neurophysiological measures related to cortical inhibitory function assessed using transcranial magnetic stimulation (TMS). The study will also explore whether baseline measures of cortical inhibition predict responsiveness to the intervention and whether changes in inhibitory activity are associated with mobility improvements following training.

This study is intended to provide preliminary data regarding the feasibility, safety, and potential benefits of combining motor imagery with locomotor turning practice to support future larger-scale rehabilitation trials targeting mobility and fall risk in older adults.

Inclusion criteria

• Age 65 years or older.
• Self-report difficulty with turning, balance, or walking-related mobility tasks.
• Self-report increased fall risk, including a history of falls, fall-related injury, multiple falls within the previous year, or fear of falling due to balance or walking concerns.
• Report some difficulty with walking-related activities, such as turning, walking longer distances, climbing stairs, or completing household activities.
• Willingness to be randomized to either study group and complete all study procedures.
• Living independently in the community and able to travel to the research site.
• Ability to perform motor imagery, defined by a qualifying score on the Motor Imagery Questionnaire - Revised Second Version.
• Access to an internet-connected computer capable of playing videos with sound in a quiet environment.
• Ability to provide informed consent.

Exclusion criteria

• Diagnosis or symptoms of a neurological disorder or central nervous system injury, including Alzheimer's disease, Parkinson's disease, multiple sclerosis, or stroke.
• Contraindications to transcranial magnetic stimulation (TMS) or non-invasive brain stimulation procedures.
• Use of medications known to substantially affect central nervous system function.
• Severe arthritis or musculoskeletal impairment that would limit safe participation in mobility training.
• Severe obesity (body mass index greater than 35 kg/m²).
• Significant cardiovascular, pulmonary, renal, or other uncontrolled medical conditions that may limit safe participation.
• Myocardial infarction or major cardiac surgery within the previous year.
• Cancer treatment within the previous year, excluding nonmelanoma skin cancer or cancers with excellent prognosis.
• Uncontrolled hypertension at rest (systolic blood pressure >180 mmHg and/or diastolic blood pressure >100 mmHg).
• Bone fracture or joint replacement within the previous 6 months.
• Current participation in physical therapy or cardiopulmonary rehabilitation targeting lower extremity function.
• Current enrollment in another clinical trial that may interfere with study participation or outcomes.
• Inability to communicate effectively with study personnel or inability to understand English-language study procedures.
• Plans to relocate from the area during the study period.
• Any additional safety or compliance concerns identified by the investigative team.