Reliability and Validity of Dual-Task Mobility Assessments in People with Chronic Stroke

Comparison of psychometric properties of the dual-task timed up-and-go test (cognitive) and the 3-m walk backward test in community-dwelling stroke patients

BACKGROUND

There is a need for practical, easy-to-use and accurately assessing balance tools in stroke patients.

OBJECTIVES

This study aimed to compare the psychometric properties of the dual-task Timed Up-and-Go test (cognitive) (DTUG) and the 3-m walk backward test (3MBWT) in stroke patients.

METHODS

This study evaluated the practicality, validity, and reliability of the DTUG and the 3MBWT. The test-retest method was used for reliability. The Modified Four Square Step Test (MFSST), the Timed Up-and-Go (TUG), and Berg Balance Scale (BBS) were administered for concurrent validity. A cutoff value was calculated to discriminate between fallers and non-fallers.

RESULTS

The mean practicality times of the tests were 63.58 ± 47.32 sec for DTUG and 37.42 ± 24.036 sec for 3MBWT. Intraclass correlation coefficient of the DTUG and 3MBWT were 0.977, 0.964, respectively which showed excellent test - retest reliability. The DTUG demonstrated strong/very strong correlations with the MFSST (r = 0.724, p < 0.001), TUG (r = 0.909, p < 0.001), and BBS (r = -0.740, p < 0.001). The 3MBWT showed strong correlations with the MFSST (r = 0.835, p < 0.001), the TUG (r = 0.799, p < 0.001), and the BBS (r = -0.740, p < 0.001). The cutoff point was 36.945 s for DTUG and 14.605 s for 3MBWT.

CONCLUSIONS

The 3MBWT was a more practical test than the DTUG; however, the DTUG was more discriminative than the 3MBWT in identifying fallers after stroke.

CLINICAL TRIAL REGISTRATION NUMBER

NCT05211349.

URL

https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000BRKZ&selectaction=Edit&uid=U0005GRO&ts=2&cx=z21bhg.

Comparing the effects of dual-task training and single-task training on walking, balance and cognitive functions in individuals with Parkinson's disease: A systematic review

BACKGROUND

This systematic review aimed to examine whether dual-task (DT) training was superior to single-task (ST) training in improving DT walking, balance and cognitive functions for individuals with Parkinson's disease (PD).

METHODS

Literature search was performed in the following electronic databases: PubMed, the Cochrane Library, Web of Science, and Metstr covering inception to May 10, 2023. And in order to facilitate comparison across trials, we calculated the effect size (Hedges' g) of gait, balance, cognitive, and other parameters under both ST and DT conditions, using the mean change score and standard deviation (SD) of change score of the experimental and control groups. Randomized controlled trials that examined the effects of DT motor and cognitive training in individuals with Parkinson's disease were included for this systematic review.

RESULTS

A total of 214 participants recruited from six articles (actually five trials) were involved in this review. In terms of walking ability, only double support time and stride time variability showed significant between-group difference (Hedges' g = 0.34, 0.18, respectively). Compared to ST training group, DT training group had a more improvement effect in laboratory balance measurement (Hedges' g = 0.18, 1.25), but no significant improvement in clinical balance measurement. No significant between-group differences were observed, thus its training effect on cognitive function was inconclusive.

CONCLUSIONS

The DT training failed to achieve promising results better than ST training in improving DT walking and balance functions for individuals with PD. Any firm conclusion cannot be drawn at present, due to the limited number of eligible publications. Larger sample size and high-quality studies are needed to investigate the effectiveness of DT training in individuals with PD.

PEMOCS: Evaluating the effects of a concept-guided, PErsonalised, MOtor-Cognitive exergame training on cognitive functions and gait in chronic Stroke-study protocol for a randomised controlled trial

BACKGROUND

Many stroke survivors remain with residual cognitive and motor impairments despite receiving timely acute and sub-acute rehabilitation. This indicates that rehabilitation following stroke should be continuous to meet the needs of individual stroke patients. Both cognitive and motor functions are essential for mastering daily life and, therefore, should be aimed at with rehabilitation. Exergames, motor-cognitive exercises performed using video games, are an auspicious method to train both motor and cognitive functions and at the same time may foster the long-term motivation for training. This study aims to assess the effect of concept-guided, personalised, motor-cognitive exergame training on cognitive and motor functions in chronic stroke survivors.

METHODS

This study is a single-blinded, randomised controlled trial. Assessments are performed at baseline, after a 12-week intervention, and at a 24-weeks follow-up. Chronic stroke patients (≥ 18 years old, ≥ 6 months post-stroke) able to stand for 3 min, independently walk 10 m, follow a two-stage command, and without other neurological diseases apart from cognitive deficits or dementia are included. Participants in the intervention group perform the exergame training twice per week for 30 (beginning) up to 40 (end) minutes additionally to their usual care programme. Participants in the control group receive usual care without additional intervention(s). Global cognitive functioning (total Montreal Cognitive Assessment (MoCA) score) is the primary outcome. Secondary outcomes include health-related quality of life, specific cognitive functions, single- and dual-task mobility, and spatiotemporal gait parameters. The target sample size for this trial is 38 participants. Linear mixed models with the post-outcome scores as dependent variables and group and time as fixed effects will be performed for analysis.

DISCUSSION

Superior improvements in global cognitive functioning and in the abovementioned secondary outcomes in the intervention group compared to the control group are hypothesised. The results of this study may guide future design of long-term rehabilitation interventions after stroke.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05524727). Registered on September 1, 2022.

Dual Tasking Affects the Outcomes of Instrumented Timed up and Go, Sit-to-Stand, Balance, and 10-Meter Walk Tests in Stroke Survivors

Stroke can impair mobility, with deficits more pronounced while simultaneously performing multiple activities. In this study, common clinical tests were instrumented with wearable motion sensors to study motor-cognitive interference effects in stroke survivors (SS). A total of 21 SS and 20 healthy controls performed the Timed Up and Go (TUG), Sit-to-Stand (STS), balance, and 10-Meter Walk (10MWT) tests under single and dual-task (counting backward) conditions. Calculated measures included total time and gait measures for TUG, STS, and 10MWT. Balance tests for both open and closed eyes conditions were assessed using sway, measured using the linear acceleration of the thorax, pelvis, and thighs. SS exhibited poorer performance with slower TUG (16.15 s vs. 13.34 s, single-task p < 0.001), greater sway in the eyes open balance test (0.1 m/s2 vs. 0.08 m/s2, p = 0.035), and slower 10MWT (12.94 s vs. 10.98 s p = 0.01) compared to the controls. Dual tasking increased the TUG time (~14%, p < 0.001), balance thorax sway (~64%, p < 0.001), and 10MWT time (~17%, p < 0.001) in the SS group. Interaction effects were minimal, suggesting similar dual-task costs. The findings demonstrate exaggerated mobility deficits in SS during dual-task clinical testing. Dual-task assessments may be more effective in revealing impairments. Integrating cognitive challenges into evaluation can optimize the identification of fall risks and personalize interventions targeting identified cognitive-motor limitations post stroke.

Post-Stroke Functional Changes: In-Depth Analysis of Clinical Tests and Motor-Cognitive Dual-Tasking Using Wearable Sensors

Clinical tests like Timed Up and Go (TUG) facilitate the assessment of post-stroke mobility, but they lack detailed measures. In this study, 21 stroke survivors and 20 control participants underwent TUG, sit-to-stand (STS), and the 10 Meter Walk Test (10MWT). Tests incorporated single tasks (STs) and motor-cognitive dual-task (DTs) involving reverse counting from 200 in decrements of 10. Eight wearable motion sensors were placed on feet, shanks, thighs, sacrum, and sternum to record kinematic data. These data were analyzed to investigate the effects of stroke and DT conditions on the extracted features across segmented portions of the tests. The findings showed that stroke survivors (SS) took 23% longer for total TUG (p < 0.001), with 31% longer turn time (p = 0.035). TUG time increased by 20% (p < 0.001) from STs to DTs. In DTs, turning time increased by 31% (p = 0.005). Specifically, SS showed 20% lower trunk angular velocity in sit-to-stand (p = 0.003), 21% longer 10-Meter Walk time (p = 0.010), and 18% slower gait speed (p = 0.012). As expected, turning was especially challenging and worsened with divided attention. The outcomes of our study demonstrate the benefits of instrumented clinical tests and DTs in effectively identifying motor deficits post-stroke across sitting, standing, walking, and turning activities, thereby indicating that quantitative motion analysis can optimize rehabilitation procedures.

Effect of High-Intensity Interval Training and Moderate-Intensity Continuous Training in People With Poststroke Gait Dysfunction: A Randomized Clinical Trial

Background The exercise strategy that yields the greatest improvement in both cardiorespiratory fitness (V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ ) and walking capacity poststroke has not been determined. This study aimed to determine whether conventional moderate-intensity continuous training (MICT) or high-intensity interval training (HIIT) have different effects on V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6-minute walk distance (6MWD). Methods and Results In this 24-week superiority trial, people with poststroke gait dysfunction were randomized to MICT (5 days/week) or HIIT (3 days/week with 2 days/week of MICT). MICT trained to target intensity at the ventilatory anaerobic threshold. HIIT trained at the maximal tolerable treadmill speed/grade using a novel program of 2 work-to-recovery protocols: 30:60 and 120:180 seconds. V̇O2 and heart rate was measured during performance of the exercise that was prescribed at 8 and 24 weeks for treatment fidelity. Main outcomes were change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ and 6MWD. Assessors were blinded to the treatment group for V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ but not 6MWD. Secondary outcomes were change in ventilatory anaerobic threshold, cognition, gait-economy, 10-meter gait-velocity, balance, stair-climb performance, strength, and quality-of-life. Among 47 participants randomized to either MICT (n=23) or HIIT (n=24) (mean age, 62±11 years; 81% men), 96% completed training. In intention-to-treat analysis, change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ for MICT versus HIIT was 2.4±2.7 versus 5.7±3.1 mL·kg-1·min-1 (mean difference, 3.2 [95% CI, 1.5-4.8]; P<0.001), and change in 6MWD was 70.9±44.3 versus 83.4±53.6 m (mean difference, 12.5 [95% CI, -17 to 42]; P=0.401). HIIT had greater improvement in ventilatory anaerobic threshold (mean difference, 2.07 mL·kg-1·min-1 [95% CI, 0.59-3.6]; P=0.008). No other between-group differences were observed. During V̇O2 monitoring at 8 and 24 weeks, MICT reached 84±14% to 87±18% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ while HIIT reached 101±22% to 112±14% of V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ (during peak bouts). Conclusions HIIT resulted in more than a 2-fold greater and clinically important change in V ̇ O 2 peak $$ \dot{\mathrm{V}}{\mathrm{O}}_{2\mathrm{peak}} $$ than MICT. Training to target (ventilatory anaerobic threshold) during MICT resulted in ~3 times the minimal clinically important difference in 6MWD, which was similar to HIIT. These findings show proof of concept that HIIT yields greater improvements in cardiorespiratory fitness than conventional MICT in appropriately screened individuals. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03006731.

Language-Specific Dual-Task Effects After Stroke: A Systematic Review

PURPOSE

The dual-task paradigm has been frequently used to examine stroke-related deficits because it samples behavioral performance under conditions of distraction similar to functioning in real-life environments. This original systematic review synthesizes studies that examined dual-task effects involving spoken language production in adults affected by stroke, including transient ischemic attack (TIA) and poststroke aphasia.

METHOD

Five databases were searched (inception to March 2022) for eligible peer-reviewed articles. The 21 included studies reported a total of 561 stroke participants. Thirteen studies focused on single word production, for example, word fluency, and eight on discourse production, for example, storytelling. Most studies included participants who had suffered a major stroke. Six studies focused on aphasia, whereas no study focused on TIA. A meta-analysis was not appropriate because of the heterogeneity of outcome measures.

RESULTS

Some single word production studies found dual-task language effects whereas others did not. This finding was compounded by the lack of appropriate control participants. Most single word and discourse studies utilized motoric tasks in the dual-task condition. Our certainty (or confidence) assessment was based on a methodological appraisal of each study and information about reliability/fidelity. As 10 of the 21 studies included appropriate control groups and limited reliability/fidelity information, the certainty of the findings may be described as weak.

CONCLUSIONS

Language-specific dual-task costs were identified in single word studies, especially those that focused on aphasia as well as half of the nonaphasia studies. Unlike single word studies, nearly all studies of discourse showed dual-task decrements on at least some variables.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23605311.

Cortical thickness is related to cognitive-motor automaticity and attention allocation in individuals with Alzheimer's disease: a regions of interest study

Alzheimer's disease (AD) is characterized by a distinct pattern of cortical thinning and resultant changes in cognition and function. These result in prominent deficits in cognitive-motor automaticity. The relationship between AD-related cortical thinning and decreased automaticity is not well-understood. We aimed to investigate the relationship between cortical thickness regions-of-interest (ROI) and automaticity and attention allocation in AD using hypothesis-driven and exploratory approaches. We performed an ROI analysis of 46 patients with AD. Data regarding MR images, demographic characteristics, cognitive-motor dual task performance, and cognition were extracted from medical records. Cortical thickness was calculated from MR T1 images using FreeSurfer. Data from the dual task assessment was used to calculate the combined dual task effect (cDTE), a measure of cognitive-motor automaticity, and the modified attention allocation index (mAAI). Four hierarchical multiple linear regression models were conducted regressing cDTE and mAAI separately on (1) hypothesis-generated ROIs and (2) exploratory ROIs. For cDTE, cortical thicknesses explained 20.5% (p = 0.014) and 25.9% (p = 0.002) variability in automaticity in the hypothesized ROI and exploratory models, respectively. The dorsal lateral prefrontal cortex (DLPFC) (β =  - 0.479, p = 0.018) and superior parietal cortex (SPC) (β = 0.467, p = 0.003), and were predictors of automaticity. For mAAI, cortical thicknesses explained 20.7% (p = 0.025) and 28.3% (p = 0.003) variability in attention allocation in the hypothesized ROI and exploratory models, respectively. Thinning of SPC and fusiform gyrus were associated with motor prioritization (β =  - 0.405, p = 0.013 and β =  - 0.632, p = 0.004, respectively), whereas thinning of the DLPFC was associated with cognitive prioritization (β = 0.523, p = 0.022). Cortical thinning in AD was related to cognitive-motor automaticity and task prioritization, particularly in the DLPFC and SPC. This suggests that these regions may play a primary role in automaticity and attentional strategy during dual-tasking.

Do the dual-task "8-foot up and go" tests provide additional predictive value for early detection of cognitive decline in community-dwelling older women?

BACKGROUND

The 8-Foot Up and Go (8UG) test is a widely used mobility assessment. Some dual-task mobility assessments have been developed to help detect cognitive decline.

AIMS

This study developed a dual-task version of 8UG test to investigate the dual-task 8UG performance and to evaluate the ability of dual-task 8UG test in detecting cognitive decline.

METHODS

A total of 101 eligible community-dwelling women aged 60-74 years were grouped into the mild cognitive impairment group (MCI, n = 49) and the non-cognitive impairment group (NCI, n = 52). The 8UG tests under single-task (ST), manual dual-task (MT), and cognitive dual-task (CT) conditions were performed respectively. The dual-task cost (DTC) and the correct response rate (CRR) were calculated to quantify the dual-task interference.

RESULTS

Participants spent more time in performing the 8UG test under dual-task conditions. No differences were observed between NCI and MCI groups for 8UG parameters under ST and MT conditions (p > 0.05). When executing CT, significant differences were found in the number of correct answers and CRR (p < 0.05). CRR showed the strongest ability to predict MCI with a cut-off point of 0.50 (71.2% sensitivity and 61.2% specificity).

DISCUSSION

Both manual and cognitive dual-task were found to interfere with the 8UG performance. CRR with cutoff point of 0.50 could be a potential predictor of MCI in community-dwelling older women.

CONCLUSIONS

The CRR of the cognitive dual-task 8UG test could be recommended as a potential predictor for the early detection of MCI in community-dwelling older women.

Frontal, Sensorimotor, and Posterior Parietal Regions Are Involved in Dual-Task Walking After Stroke

Background

Walking within the community requires the ability to walk while simultaneously completing other tasks. After a stroke, completing an additional task while walking is significantly impaired, and it is unclear how the functional activity of the brain may impact this.

Methods

Twenty individual in the chronic stage post-stroke participated in this study. Functional near-infrared spectroscopy (fNIRS) was used to measure prefrontal, pre-motor, sensorimotor, and posterior parietal cortices during walking and walking while completing secondary verbal tasks of varying difficulty. Changes in brain activity during these tasks were measured and relationships were accessed between brain activation changes and cognitive or motor abilities.

Results

Significantly larger activations were found for prefrontal, pre-motor, and posterior parietal cortices during dual-task walking. Increasing dual-task walking challenge did not result in an increase in brain activation in these regions. Higher general cognition related to lower increases in activation during the easier dual-task. With the harder dual-task, a trend was also found for higher activation and less motor impairment.

Conclusions

This is the first study to show that executive function, motor preparation/planning, and sensorimotor integration areas are all important for dual-task walking post-stroke. A lack of further brain activation increase with increasing challenge suggests a point at which a trade-off between brain activation and performance occurs. Further research is needed to determine if training would result in further increases in brain activity or improved performance.

Cognitive-Motor Interference during Dual Tasks in Blind Children

The aim of the present study was to compare the dual-task (DT) performance in blind children with sighted ones while concurrently performing a motor task (upright standing) with cognitive (Letter fluency (LF) or Category fluency (CF)) tasks. The Center of pressure mean velocity (CoP_Vm) and the cognitive performances were recorded during single (ST) and DT conditions. Results showed that, for both groups, CoP_Vm values increased significantly (p < 0.05) in the DT compared to ST condition. The CoP_Vm values were significantly (p < 0.001) higher in blind children, compared to controls only in the DT-CF condition. In conclusion, balance performance of blind and typically developed children is affected by dual tasking. Interference between motor and cognitive tasks has more pronounced effects on balance performance in blind children, compared to controls. This difference was observed only when performing the CF task concurrently with the postural balance task.

A Novel Way of Measuring Dual-Task Interference: The Reliability and Construct Validity of the Dual-Task Effect Battery in Neurodegenerative Disease

BACKGROUND

Decreased automaticity is common among individuals with neurodegenerative disease and is often assessed using dual-task (DT) paradigms. However, the best methods for assessing performance changes related to DT demands remain inconclusive.

OBJECTIVE

To investigate the reliability and validity of a novel battery of DT measures (DT Effect-Battery (DTE-B)) encompassing three domains: task-specific interference, task prioritization, and automaticity.

METHODS

Data for this retrospective cross-sectional study included 125 participants with Parkinson's disease (PD), 127 participants with Alzheimer's disease (AD), and 84 healthy older adults. Reliability analyses were conducted using a subset of each population. DTE-B measures were calculated from single and DT performance on the Timed Up and Go test and a serial subtraction task. Construct validity was evaluated via associations within the DTE-B and with theoretically supported measures as well as known-groups validity analyses.

RESULTS

Good to excellent reliability was found for DTE-B measures of task interference (motor and cognitive DT effects) (ICCs≥.658) and automaticity (combined DT effect (cDTE)) (ICCs≥.938). Evidence for convergent validity was found with associations within the hypothesized constructs. Known-groups validity analyses revealed differences in the DTE-B among the healthy group and PD and AD groups (ps≤.001), excepting task prioritization (ps≥.061).

CONCLUSIONS

This study provides evidence to support the DTE-B as a reliable measure of multiple constructs pertinent to DT performance. The cDTE demonstrated evidence to support its validity as a measure of automaticity. Further investigation of the utility of the DTE-B in both PD and AD, as well as other populations, is warranted.

Cerebral Microbleeds Were Related With Poor Cognitive Performances on the Dual Task Condition in Older Adults

Background: The dual task (DT) was commonly used to assess the risk of falls in older adults and patients with neurological disorders. However, the performance on DT conditions has not been well investigated in patients with cerebral microbleed (CMB). This study is aimed to compare the performance in DT tests between older adults with and without CMB, and to explore the association between CMB and cognitive performances of DT.

Methods: This is a cross-sectional study. A total of 211 old adults participated, involving 68 CMB patients. The task protocol involved two global cognition tests, two single cognitive tests (serial 7 subtraction and semantic fluency), two single motor tasks [8-m walking and timed up and go test (TUG)], and three DT tests [walking and serial subtraction (WSS), walking and semantic fluency (WSF), and TUG and serial subtraction (TUGSS)]. The time taken to complete each task and the number of correct responses were recorded. For each DT condition, the correct response rate (CRR) and the dual-task effect (DTE) for the correct number were calculated.

Results: Compared with subjects without CMB, CMB patients had worse cognitive performances on DT condition in CRR of WSS (p = 0.003), WSF (p = 0.030) and TUGSS (p = 0.006), and DTE of WSS (p = 0.017). Binary logistic regression analysis showed that the presence of CMB was an independent risk factor for the impairment group for CRR of TUGSS (OR, 2.54; 95% CI, 1.11–5.82; p = 0.027) with the adjustment for confounders, rather than CRR of WSS and WSF, or DTE of WSS. Multiple linear regression analysis showed that CRR of TUGSS decreased with the increase of CMB number grades (β, −0.144; 95% CI, −0.027, −0.002; p = 0.028).

Conclusion: The present study indicated that CMBs were closely associated with poor cognitive performances on DT in the elderly. Strongest effect size was seen for CRR of TUGSS, where performance deficits increased in proportion to the degree of CMB burden.

Dual Task Performance Is Associated with Amyloidosis in Cognitively Healthy Adults

BACKGROUND

Preclinical Alzheimer's disease (AD) provides an opportunity for the study and implementation of interventions and strategies aimed at delaying, mitigating, and preventing AD. While this preclinical state is an ideal target, it is difficult to identify efficiently and cost-effectively. Recent findings have suggested that cognitive-motor dual task paradigms may provide additional inference.

OBJECTIVES

Investigate the relationship between dual task performance and amyloidosis, suggestive of preclinical Alzheimer's disease and whether dual task performance provides additional information beyond a cognitive composite, to help in the identification of amyloidosis.

DESIGN

Cross-sectional.

SETTING

Outpatient specialty brain health clinical research institution in the United States.

PARTICIPANTS

52 cognitively healthy adults.

MEASUREMENTS

The data included demographics, amyloid standardized uptake value ratio obtained via florbetapir-PET, neuropsychological testing, apolipoprotien E genotype, and dual task performance measures. Data were analyzed via hierarchal multiple linear regression or logistic regression, controlling for age, education, and apolipoprotien E genotype. Receiver operating characteristic curves were plotted, and sensitivity and specificity calculated via 2x2 contingency tables.

RESULTS

There was a moderate relationship (rs>.30) between motor and cognitive dual task effects and amyloid standardized uptake value ratio (ps<.042). A strong relationship (r=.58) was found between combined dual task effect, a measure of automaticity derived from dual task performance, and amyloid standardized uptake value ratio (p<.001). Additionally, combined dual task effect showed promise in its unique contributions to amyloid standardized uptake value ratio, accounting for 7.8% of amyloid standardized uptake value ratio variance beyond cognitive composite scores (p=.018). Additionally, when incorporated into the cognitive composite, combined dual task effect resulted in improved diagnostic accuracy for determining elevated amyloid standardized uptake value ratio, and increased the sensitivity and specificity of the cognitive composite.

CONCLUSSION

Dual task performance using the combined dual task effect, a measure of automaticity, was a moderate predictor of cerebral amyloidosis, which suggests that it has utility in the screening and diagnosis of individuals for preclinical AD. Additionally, when combined with the cognitive composite, the combined dual task effect improves diagnostic accuracy. Further research is warranted.

The effects of a secondary task on gait in axial spondyloarthritis

Studies on the effects of dual tasking in patients with chronic inflammatory rheumatic diseases are limited. The aim of this study was to assess dual tasking while walking in patients with axial spondyloarthritis (axSpA) in comparison to healthy controls. Thirty patients with axSpA and thirty healthy controls underwent a 10-m walk test at a self-selected comfortable walking speed in single- and dual-task conditions. Foot-worn inertial sensors were used to compute spatiotemporal gait parameters. Analysis of spatiotemporal gait parameters showed that the secondary manual task negatively affected walking performance in terms of significantly decreased mean speed (p < 0.001), stride length (p < 0.001) and swing time (p = 0.008) and increased double support (p = 0.002) and stance time (p = 0.008). No significant interaction of group and condition was observed. Both groups showed lower gait performance in dual task condition by reducing speed, swing time and stride length, and increasing double support and stance time. Patients with axSpA were not more affected by the dual task than matched healthy controls, suggesting that the secondary manual task did not require greater attention in patients with axSpA. Increasing the complexity of the walking and/or secondary task may increase the sensitivity of the dual-task design to axial spondyloarthritis.

Task matters: an investigation on the effect of different secondary tasks on dual-task gait in older adults

Background

Dual-task gait performance declines as humans age, leading to increased fall risk among older adults. It is unclear whether different secondary cognitive tasks mediate age-related decline in dual-task gait. This study aimed to examine how type and difficulty level of the secondary cognitive tasks differentially affect dual-task gait in older adults.

Methods

Twenty young and twenty older adults participated in this single-session study. We employed four different types of secondary tasks and each consisted of two difficulty levels, yielding eight different dual-task conditions. The dual-task conditions included walking and 1) counting backward by 3 s or by 7 s; 2) remembering a 5-item or 7-item lists; 3) responding to a simple or choice reaction time tasks; 4) generating words from single or alternated categories. Gait speed and cognitive task performance under single- and dual-task conditions were used to compute dual-task cost (DTC, %) with a greater DTC indicating a worse performance.

Results

A significant three-way interaction was found for the gait speed DTC (p = .04). Increased difficulty in the reaction time task significantly increased gait speed DTC for older adults (p = .01) but not for young adults (p = .90). In contrast, increased difficulty level in the counting backward task significantly increased gait speed DTC for young adults (p = .03) but not for older adults (p = .85). Both groups responded similarly to the increased task difficulty in the other two tasks.

Conclusions

Older adults demonstrated a different response to dual-task challenges than young adults. Aging might have different impacts on various cognitive domains and result in distinctive dual-task gait interference patterns.

Psychometric Properties of Cognitive-Motor Dual-Task Studies With the Aim of Developing a Test Protocol for Persons With Vestibular Disorders: A Systematic Review

OBJECTIVES

Patients suffering from vestibular disorders (VD) often present with impairments in cognitive domains such as visuospatial ability, memory, executive function, attention, and processing speed. These symptoms can be attributed to extensive vestibular projections throughout the cerebral cortex and subcortex on the one hand, and to increased cognitive-motor interference (CMI) on the other hand. CMI can be assessed by performing cognitive-motor dual-tasks (DTs). The existing literature on this topic is scarce and varies greatly when it comes to test protocol, type and degree of vestibular impairment, and outcome. To develop a reliable and sensitive test protocol for VD patients, an overview of the existing reliability and validity studies on DT paradigms will be given in a variety of populations, such as dementia, multiple sclerosis, Parkinson's disease, stroke, and elderly.

DESIGN

The systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An extensive literature search on psychometric properties of cognitive-motor DTs was run on MEDLINE, Embase, and Cochrane Databases. The studies were assessed for eligibility by two independent researchers, and their methodological quality was subsequently evaluated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN).

RESULTS AND CONCLUSIONS

Thirty-three studies were included in the current review. Based on the reliability and validity calculations, including a static as well as dynamic motor task seems valuable in a DT protocol for VD patients. To evoke CMI maximally in this population, both motor tasks should be performed while challenging the vestibular cognitive domains. Out of the large amount of cognitive tasks employed in DT studies, a clear selection for each of these domains, except for visuospatial abilities, could be made based on this review. The use of the suggested DTs will give a more accurate and daily life representation of cognitive and motor deficiencies and their interaction in the VD population.

Timed "Up & Go" Dual-Task Tests: Age- and Sex-Specific Reference Values and Test-Retest Reliability in Cognitively Healthy Controls

OBJECTIVE

The purpose of the study was to establish reference values for the Uppsala-Dalarna Dementia and Gait (UDDGait) Timed "Up & Go" dual-task (TUGdt) test variables in cognitively healthy adults and to assess these variables' test-retest reliability.

METHODS

For reference values, 166 participants were recruited with approximately equal numbers and proportions of women and men in the age groups 50 to 59, 60 to 69, 70 to 79, and 80+ years (mean age = 70 years, age range = 50-91 years, 51% women). For reliability testing, 43 individuals (mean age = 69 years, age range = 50-89 years, 51% women) were recruited. Two dt tests were carried out: TUGdt naming animals and TUGdt months backward, representing 8 test variables: time scores, costs (the relative difference between single-task and dt time scores), "number of animals," "number of months," "animals/10 seconds ," and "months/10 seconds ." Reference ranges for the variables were established by quantile regression in age- and sex-specific groups. For reliability, intraclass correlation coefficients (ICCs), standard error of measurement, minimal detectable change, and Bland-Altman plots were used.

RESULTS

Reference values for the TUGdt test variables are presented for the 2.5th and 97.5th percentiles. The reliability of TUGdt time scores was excellent (ICCs between 0.85 and 0.86). "Number of animals" and "animals/10 seconds" as well as "months/10 seconds" showed fair to good levels of reliability (ICCs between 0.45 and 0.58), whereas the reliability for both cost measures and "number of months" was poor (ICCs between 0.34 and 0.39).

CONCLUSION

Normative reference values, potentially useful for clinical and research purposes, were presented in 4 age- and sex-specific groups from 50 years and older. Reliability for the test variables varied between poor and excellent, the lower estimates partly explained by some variables being the ratio of 2 other variables. In UDDGait, TUGdt tests are intended for diagnostic and predictive purposes, for which these tests are promising and require further investigations.

IMPACT

Normative reference values and test-retest reliability results for the UDDGait TUGdt test variables were presented. These results should be useful for both clinical and research purposes.

Gait Variability and Complexity during Single and Dual-Task Walking on Different Surfaces in Outdoor Environment

Nowadays, gait assessment in the real life environment is gaining more attention. Therefore, it is desirable to know how some factors, such as surfaces (natural, artificial) or dual-tasking, influence real life gait pattern. The aim of this study was to assess gait variability and gait complexity during single and dual-task walking on different surfaces in an outdoor environment. Twenty-nine healthy young adults aged 23.31 ± 2.26 years (18 females, 11 males) walked at their preferred walking speed on three different surfaces (asphalt, cobbles, grass) in single-task and in two dual-task conditions (manual task-carrying a cup filled with water, cognitive task-subtracting the number 7). A triaxial inertial sensor attached to the lower trunk was used to record trunk acceleration during gait. From 15 strides, sample entropy (SampEn) as an indicator of gait complexity and root mean square (RMS) as an indicator of gait variability were computed. The findings demonstrate that in an outdoor environment, the surfaces significantly impacted only gait variability, not complexity, and that the tasks affected both gait variability and complexity in young healthy adults.

Spatio-temporal gait parameters obtained from foot-worn inertial sensors are reliable in healthy adults in single- and dual-task conditions

Inertial measurement units (IMUs) are increasingly popular and may be usable in clinical routine to assess gait. However, assessing their intra-session reliability is crucial and has not been tested with foot-worn sensors in healthy participants. The aim of this study was to assess the intra-session reliability of foot-worn IMUs for measuring gait parameters in healthy adults. Twenty healthy participants were enrolled in the study and performed the 10-m walk test in single- and dual-task ('carrying a full cup of water') conditions, three trials per condition. IMUs were used to assess spatiotemporal gait parameters, gait symmetry parameters (symmetry index (SI) and symmetry ratio (SR)), and dual task effects parameters. The relative and the absolute reliability were calculated for each gait parameter. Results showed that spatiotemporal gait parameters measured with foot-worn inertial sensors were reliable; symmetry gait parameters relative reliability was low, and SR showed better absolute reliability than SI; dual task effects were poorly reliable, and taking the mean of the second and the third trials was the most reliable. Foot-worn IMUs are reliable to assess spatiotemporal and symmetry ratio gait parameters but symmetry index and DTE gait parameters reliabilities were low and need to be interpreted with cautious by clinicians and researchers.

The effects of virtual reality augmented robot-assisted gait training on dual-task performance and functional measures in chronic stroke: a randomized controlled single-blind trial

BACKGROUND

Many studies have demonstrated positive effects of virtual reality (VR) and robot-assisted gait training (RAGT) on balance, gait skills, functional capacity, active participation, and motivation in stroke patients, previously. However, the effects of VR augmented RAGT on dual-task performance which requires simultaneous use of motor and cognitive parameters have not been investigated.

AIM

To primarily investigate the effects of virtual reality (VR) augmented robot-assisted gait training (RAGT) on dual-task performance and secondarily, functional measurements in chronic stroke patients.

DESIGN

A randomized, single-blind trial.

SETTING

Inpatient rehabilitation center.

POPULATION

The study included 30 chronic stroke patients aged between 40-65 with the level of ≥3 from Functional Ambulation Classification and ≥24 from the Standardized Mini Mental State Examination.

METHODS

Fifteen patients in the study group received VR augmented RAGT and 15 patients in the control group received only RAGT during 12 sessions (six weeks). All patients received neurodevelopmental therapy in addition to their treatments, simultaneously. To evaluate dual-task performance, motor and cognitive tasks were given in addition to the 10 Meter Walk (first motor task), and durations were recorded in seconds. Functional measures such as Functional Gait Assessment, Rivermead Mobility Index, Berg Balance Scale, Fall Activity Scale International, and the Functional Independence Measure for gait, mobility, balance, fear of falling, and independence in daily living activities were also applied, consecutively.

RESULTS

The mean age of the study population was 57.93±5.91. After the treatment, single and dual-task gait speeds and cognitive dual-task performance increased in the study group (P<0.05), while no change was observed in the control group (P>0.05). No significant difference was detected between the groups in terms of all assessments after the treatment (P>0.05).

CONCLUSIONS

This study demonstrated that VR augmented RAGT improved dual-task gait speeds and dual-task performance of chronic stroke patients; however, there were no difference between the two groups after the treatment. Although functional improvements were determined with VR combined RAGT approach, it was not superior to RAGT only treatment.

CLINICAL REHABILITATION IMPACT

The results of current study suggest the simultaneous use of VR as an adjunct therapy method to the functional training to obtain functional gains in ambulant patients with chronic stroke.

Test-retest reliability of the functional reach test and the hand grip strength test in older adults using nursing home services

OBJECTIVE

This study aimed to determine the absolute and relative test-retest reliability of the functional reach test (FRT) and the handgrip strength test (HGST) in older adults using nursing homes.

METHODS

Participants (≥ 65 years old), living in nursing homes or using their day care services, were distributed into a group without cognitive impairment (GWCI, n = 43) and a group with mild cognitive impairment (GCI; n = 22). A 1-week test-retest was performed for the FRT and the HGST. Relative reliability was measured by the intraclass correlation coefficient (ICC_3.1), and absolute reliability by the standard error of measurement (SEM), minimal detectable change (MDC₉₅), and Bland-Altman plots.

RESULTS

The ICC showed high reliability for the FRT (GWCI, ICC = 0.83; GCI, ICC = 0.87) and the HGST (ICC ≥ 0.95 in both hands and participant groups). The absolute reliability was good: FRT, SEM = 2.96/2.29, MDC₉₅ = 8.20/6.35 for the GWCI and the GCI, respectively; HGST dominant hand SEM = 1.26/0.82, MDC₉₅ = 3.50/2.29, and HGST non-dominant hand SEM = 1.05/0.80, MDC₉₅ = 2.90/2.21, for the GWCI and the GCI, respectively. Bland-Altman showed that there was not a systematic bias for the tests in both groups.

DISCUSSION

Findings show that the FRT and the HGST are reliable, have acceptable measurement error, and may be used for research and clinical purposes to assess functional balance and strength of the hands in older adults using nursing homes.

Cognitive-motor dual-task gait training within 3 years after stroke: A randomized controlled trial

Background: Dual-task gait training may improve dual-task gait speed after stroke, but the effects on the relative amount of dual-task interference are unclear.Objective: To compare the efficacy of dual-task gait training (DTGT) and single-task gait training (STGT) on cognitive-motor dual-task interference after stroke.Methods: 36 adults within 3 years of stroke were randomized 1:1 to STGT or DTGT, 3 times a week for 4 weeks. The primary outcomes were the relative dual-task effect on gait speed (DTEg, %) and cognitive task performance (DTEc, %) during walking at preferred and fast speed in two different dual-task conditions (auditory Stroop, auditory clock task).Results: There were no treatment effects on DTEg or DTEc in either group for either dual-task at either walking speed. Across all participants, there were significant improvements in both single and dual-task gait speed in all conditions, without any relative change in the dual-task effect. Subgroup analysis suggested that those with greater interference at baseline may benefit more from DTGT.Conclusions: DTGT and STGT improved single and dual-task gait speed but did not change the amount of relative interference. The findings may be confounded by an unexpectedly small amount of gait-related dual-task interference at baseline.

Foot-Worn Inertial Sensors Are Reliable to Assess Spatiotemporal Gait Parameters in Axial Spondyloarthritis under Single and Dual Task Walking in Axial Spondyloarthritis

The aim of this study was (1) to evaluate the relative and absolute reliability of gait parameters during walking in single- and dual-task conditions in patients with axial spondyloarthritis (axSpA), (2) to evaluate the absolute and relative reliability of dual task effects (DTE) parameters, and (3) to determine the number of trials required to ensure reliable gait assessment, in patients with axSpA. Twenty patients with axSpa performed a 10-m walk test in single- and dual-task conditions, three times for each condition. Spatiotemporal, symmetry, and DTE gait parameters were calculated from foot-worn inertial sensors. The relative reliability (intraclass correlation coefficients-ICC) and absolute reliability (standard error of measurement-SEM and minimum detectable change-MDC) were calculated for these parameters in each condition. Spatiotemporal gait parameters showed good to excellent reliability in both conditions (0.59 < ICC < 0.90). The reliability of symmetry and DTE parameters was low. ICC, SEM, and MDC were better when using the mean of the second and the third trials. Spatiotemporal gait parameters obtained from foot-worn inertial sensors assessed in patients with axSpA in single- and dual-task conditions are reliable. However, symmetry and DTE parameters seem less reliable and need to be interpreted with caution. Finally, better reliability of gait parameters was found when using the mean of the 2nd and the 3rd trials.

Patterns of cognitive-motor dual-task interference post stroke: an observational inpatient study at hospital discharge

BACKGROUND

Many ambulatory stroke survivors are discharged to community settings where they will confront highly attention-demanding mobility situations. Very little is known about cognitive-motor interference during walking in acutely rehabilitating stroke survivors.

AIM

To examine the magnitude and patterns of cognitive-motor dual-task interference at hospital discharge post stroke and explore the characteristics associated with distinct interference patterns.

DESIGN

Observational study.

SETTING

Acute care and inpatient rehabilitation centers.

POPULATION

Forty-seven adults with hospital admission for stroke who were being discharged to home. Mean age was 59.5 years (SD=11.7) and median days post stroke was 14 (IQR=7-21).

METHODS

Gait and cognitive (category naming task) performance were assessed under single- and dual-task conditions at hospital discharge. Dependent variables were gait speed, stride duration, stride duration variability, stride length, cadence, and correct response rate. Single and dual-task values were compared to assess the effects of dual-tasking on gait and category naming. Relative dual-task effects on gait speed and cognitive performance were plotted to identify patterns of dual-task interference. Exploratory analysis compared clinical characteristics between subgroups defined by pattern of interference.

RESULTS

There were significant dual-task declines in gait speed, with corresponding dual-task effects on stride length, cadence, and stride duration, but no dual-task effects on stride duration variability or correct response rate. Dual-task effects on the category naming task were not significant due to large between-subject variability. Three predominant patterns of cognitive-motor interference were evident: mutual interference (37% of participants), gait interference (30% of participants), and cognitive-priority trade-off (22% of participants) - these patterns reflect the consistently observed negative dual-task effect on gait speed with positive, negative, or null effects on category naming. Participants who demonstrated cognitive-priority trade-off pattern of interference had significantly worse single-task category-naming performance, while those with mutual interference had greater overall stroke severity.

CONCLUSIONS

Cognitive-motor dual-task interference on gait speed is highly prevalent in ambulatory stroke survivors with mild cognitive-linguistic impairments at hospital discharge. Variability in cognitive-task performance under dual-task conditions has implications for the reliability of dual-task assessment after stroke.

CLINICAL REHABILITATION IMPACT

Assessment of dual-task walking is feasible as a predischarge evaluation of attention-demanding mobility function after stroke.

Cognitive-Locomotor Dual-Task Interference in Stroke Survivors and the Influence of the Tasks: A Systematic Review

Background: Walking in the community can be challenging for stroke survivors. The fact that community walking often requires performing another task while walking further adds to this challenge and can lead to a deterioration of performance in one or both tasks. Objective: To review the existing literature about cognitive-locomotor dual-task interference (DTI) magnitude and pattern while walking in patients with stroke and to explore the influence of tasks' nature on DTI. Moreover, this review investigated the differences in DTI between stroke survivors and age-matched healthy adults. Methods: The literature search was conducted in 4 databases (MEDLINE, CINAHL, EMBASE and PEDro). Two authors independently identified relevant studies based on predetermined selection criteria. Among these criteria, studies had to include both locomotor and cognitive DTI. Methodological quality of the studies was independently assessed by two raters using a standardized checklist. Studies were categorized according to the nature of the locomotor and the cognitive tasks. Results: A total of twenty studies, with good to high methodological quality, were selected. Task combinations, outcome measures and participants characteristics varied widely from one study to another. Despite heterogeneous results across studies, mutual DTI (decrements in both locomotor and cognitive performance) was the most frequently observed pattern in participants with stroke. Interestingly, this DTI pattern was systematically obtained when participants had to avoid obstacles while walking. DTI seemed also to be influenced by the nature of the cognitive task. Compared to age-matched healthy participants, stroke survivors had greater DTI. Mutual interferences were also more frequently observed in stroke survivors than in age-matched healthy adults. Conclusions: DTI magnitude and pattern in persons with stroke varied considerably across studies. Multiple factors, including nature of the tasks, may influence dual-task abilities when assessing individuals with stroke. Consequently, dual-task assessments should be performed in similar contexts of individuals' daily lives to ensure ecological validity.

Minimal Detectable Change in Dual-Task Cost for Older Adults With and Without Cognitive Impairment

BACKGROUND AND PURPOSE

Dual-task (DT) training has become a common intervention for older adults with balance and mobility limitations. Minimal detectable change (MDC) of an outcome measure is used to distinguish true change from measurement error. Few studies reporting on reliability of DT outcomes have reported MDCs. In addition, there has been limited methodological DT research on persons with cognitive impairment (CI), who have relatively more difficulty with DTs than persons without CI. The purpose of this study was to describe test-retest reliability and MDC for dual-task cost (DTC) in older adults with and without CI and for DTs of varying difficulty.

METHODS

Fifty participants 65 years and older attended 2 test sessions within 7 to 19 days. Participants were in a high cognitive group (n = 27) with a Montreal Cognitive Assessment (MoCA) score of 26 or more, or a low cognitive group (n = 23) with a MoCA score of less than 26. During both sessions, we used a pressure-sensing walkway to collect gait data from participants. We calculated motor DTC (the percent decline in motor performance under DT relative to single-task conditions) for 4 DTs: the Timed Up and Go (TUG) while counting forward by ones (TUG1) and counting backward by threes (TUG3); and self-selected walking speed (SSWS) with the same secondary tasks (SSWS1 and SSWS3). Intraclass correlation coefficients (ICCs) and MDCs were calculated for DTC for the time to complete the TUG and spatiotemporal gait variables during SSWS. A 3-way analysis of variance was used to compare differences in mean DTC between groups, tasks, and sessions.

RESULTS AND DISCUSSION

ICCs varied across groups and tasks, ranging from 0.02 to 0.76. MDCs were larger for individuals with low cognition and for DTs involving counting backward by threes. For example, the largest MDC was 503.1% for stride width during SSWS3 for individuals with low cognition, and the smallest MDC was 5.6% for cadence during SSWS1 for individuals with high cognition. Individuals with low cognition demonstrated greater DTC than individuals with high cognition. SSWS3 and TUG3 resulted in greater DTC than SSWS1 and TUG1. There were no differences in DTC between sessions for any variable.

CONCLUSIONS

Our study provides MDCs for DTC that physical therapists may use to assess change in older adults who engage in DT training. Persons with low cognition who are receiving DT training must exhibit greater change in DTC before one can be confident the change is real. Also, greater change must be observed for more challenging DTs. Thus, cognitive level and task difficulty should be considered when measuring change with DT training.

Association of subsequent falls with evidence of dual-task interference while walking in community-dwelling individuals after stroke

Objective:

The aim of this study was to examine the fall predictive value of single-task walking tests and extent of interference observed in dual-task walking tests in ambulatory individuals post stroke.

Design:

This is an observational study with prospective cohort.

Setting:

The study was conducted at the university laboratory.

Participants:

A total of 91 community-dwelling individuals with chronic stroke participated in the study.

Main outcome measures:

Time required to complete a 10-m walk test with and without obstacle negotiation was measured in isolation and in conjunction with performance of a verbal fluency task (category naming). Fall incidence, circumstances, and related injuries were recorded by monthly telephone calls for 12 months.

Results:

A total of 91 individuals (mean (SD) age = 62.7 (8.3) years; mean (SD) post-stroke duration = 8.8 (5.3) years) participated in the study; 29 (32%) of them reported at least one fall during the follow-up period, with a total of 71 fall episodes. There was a significant difference in obstacle-crossing time under single-task (mean difference = 8.3 seconds) and dual-task (mean difference = 7.4 seconds) conditions, and also the degree of interference in mobility performance (increased dual-task obstacle-crossing time relative to the single-task obstacle-crossing time; mean difference = 3.3%) between the fallers and the non-fallers ( P < 0.05). After adjusting for the effects of other relevant factors, a greater degree of interference in mobility performance remained significantly associated with a decreased risk of falling (adjusted odds ratio = 0.951, 95% CI = 0.907–0.997, P = 0.037).

Conclusion:

The degree of mobility interference during dual-task obstacle-crossing was the most effective in predicting falls among all the single-task and dual-task walking measure parameters tested. This simple dual-task walking assessment has potential clinical utility in identifying people post stroke at high risk of future falls.

Selection of the Better Dual-Timed Up and Go Cognitive Task to Be Used in Patients With Stroke Characterized by Subtraction Operation Difficulties

Background: The Timed Up and Go Test (TUG) with serial subtraction is commonly used to assess cognitive-dual task performance during walking for fall prediction. Some stroke patients cannot perform number subtraction and it is unclear which cognitive task can be used to substitute for the subtraction task in the TUG test. The aim of this study was to determine the type of cognitive task that produced the highest decrease on both motor and cognitive performances during TUG-dual in stroke patients.

Methods: A total of 23 persons with stroke but capable of completing subtraction (ST) and 19 persons with subtraction operation difficulties (SOD) participated. Both groups have a similar age range (ST: 59.3 ± 10.4 years and SOD: 62.0 ± 6.8 years) and stroke onset duration (ST: 44.13 ± 62.29 months and SOD: 42.34 ± 39.69 months). The participants performed TUG without a cognitive task (TUG-single) followed by a cognitive task when seated (cognitive-single). In addition, TUG with a cognitive task (TUG-dual) was performed, with the activity randomly selected from four cognitive tasks, including alternate reciting, auditory working memory, clock task, and phonologic fluency. The main outcome variables—TUG duration measured by OPAL accelerometer and cognitive-dual task effect (DTE)—were analyzed using repeated-measures analyses of variance (ANOVA).

Results: The number of correct responses when seated were significantly lower in the SOD as compared to the ST (p < 0.05) during all cognitive tasks, except the phonologic fluency. During TUG-cognitive, TUG duration in the ST was significantly longer for all cognitive tasks compared with TUG-single (p < 0.0001), whereas TUG duration in the SOD was significantly increased only during the phonologic fluency task (p < 0.01). In the ST, there was a significant difference in cognitive DTE between the subtraction and the phonologic fluency tasks (p < 0.01). The highest cognitive cost was found in the subtraction task, whereas the highest cognitive benefit was shown in the phonologic fluency task. No significant cognitive DTE was found among the cognitive tasks in the SOD.

Conclusion: For stroke persons with SOD, phonologic fluency is suitable to be used in the TUG-cognitive assessment. In contrast, subtraction (by 3s) is recommended for the assessment of TUG-cognitive in stroke persons who can perform subtraction.

Brain volumes and dual-task performance correlates among individuals with cognitive impairment: a retrospective analysis

Cognitive impairment (CI) is a prevalent condition characterized by loss of brain volume and changes in cognition, motor function, and dual-tasking ability. To examine associations between brain volumes, dual-task performance, and gait and balance in those with CI to elucidate the mechanisms underlying loss of function. We performed a retrospective analysis of medical records of patients with CI and compared brain volumes, dual-task performance, and measures of gait and balance. Greater cognitive and combined dual-task effects (DTE) are associated with smaller brain volumes. In contrast, motor DTE is not associated with distinct pattern of brain volumes. As brain volumes decrease, dual-task performance becomes more motor prioritized. Cognitive DTE is more strongly associated with decreased performance on measures of gait and balance than motor DTE. Decreased gait and balance performance are also associated with increased motor task prioritization. Cognitive DTE appears to be more strongly associated with decreased automaticity and gait and balance ability than motor DTE and should be utilized as a clinical and research outcome measure in this population. The increased motor task prioritization associated with decreased brain volume and function indicates a potential for accommodative strategies to maximize function in those with CI. Counterintuitive correlations between motor brain volumes and motor DTE in our study suggest a complicated interaction between brain pathology and function.

Design, Development, and Testing of an App for Dual-Task Assessment and Training Regarding Cognitive-Motor Interference (CMI-APP) in People With Multiple Sclerosis: Multicenter Pilot Study

Background

Dual tasking constitutes a large portion of most activities of daily living; in real-life situations, people need to not only maintain balance and mobility skills, but also perform other cognitive or motor tasks at the same time. Interest toward dual-task training (DTT) is increasing as traditional interventions may not prepare patients to adequately face the challenges of most activities of daily living. These usually involve simultaneous cognitive and motor tasks, and they often show a decline in performance. Cognitive-motor interference (CMI) has been investigated in different neurological populations, but limited evidence is present for people with multiple sclerosis (MS). The use of computerized tools is mandatory to allow the application of more standardized assessment and rehabilitation intervention protocols and easier implementation of multicenter and multilanguage studies.

Objective

To describe the design and development of CMI-APP, an adaptive and interactive technology tablet-based app, and to present the preliminary results of a multicenter pilot study involving people with MS performed in several European centers for evaluating the feasibility of and adherence to a rehabilitation program based on CMI-APP.

Methods

CMI-APP includes user-friendly interfaces for personal data input and management, assessment of CMI, and DTT. A dedicated team developed CMI-APP for Android tablets above API level 14 (version 4.0), using C# as the programming language and Unity and Visual Studio as development tools. Three cognitive assessment tests for working memory, information processing speed, and sustained attention and four motor assessment tests for walking at different difficulty levels were implemented. Dual cognitive-motor tasks were performed by combining single cognitive and motor tasks. CMI-APP implements exercises for DTT involving the following 12 cognitive functions: sustained attention, text comprehension, verbal fluency, auditory discrimination, visual discrimination, working memory, information processing speed, auditory memory, visual memory, verbal analog reasoning, visual analog reasoning, and visual spatial planning, which can be performed during walking or stepping on the spot. Fifteen people with MS (mean age 52.6, SD 8.6 years; mean disease duration 9.4, SD 8.4 years; mean Expanded Disability Status Scale score 3.6, SD 1.1) underwent DTT (20 sessions). Adherence to the rehabilitation program was evaluated according to the percentage of performed sessions, perceived exertion during the training (Borg 15-point Ratings of Perceived Exertion [RPE] Scale), and subjective experience of the training (Intrinsic Motivation Inventory [IMI]).

Results

The adherence rate was 91%. DTT was perceived as “somewhat difficult” (mean RPE Scale score 12.6, SD 1.9). IMI revealed that participants enjoyed the training and felt that it was valuable and, to some extent, important, without feelings of pressure. They felt competent, although they did not always feel they could choose the exercises, probably because the therapist chose the exercises and many exercises had few difficulty levels.

Conclusions

CMI-APP is safe, highly usable, motivating, and well accepted for DTT by people with MS. The findings are fundamental for the preparation of future large-sample studies examining CMI and the effectiveness of DTT interventions with CMI-APP in people with MS.

Evaluating the Measurement Properties of the ScanCourse, a Dual-Task Assessment of Visual Scanning

IMPORTANCE

The ScanCourse is used by occupational therapists to evaluate visual scanning ability during locomotion. Its measurement properties have not been examined.

OBJECTIVE

To assess the interrater reliability, test-retest reliability, and construct validity of the ScanCourse.

DESIGN

This study involved data collection at two time points. To assess test-retest reliability, the ScanCourse was administered twice within a 2-week period. To assess interrater reliability, a second rater was present for one session. To assess level of agreement, a Bland-Altman plot was created. To assess absolute reliability, the standard error of measurement was calculated. To evaluate construct validity, the results of the ScanCourse were compared with results of the Bells Test and Trail Making Test A and B.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Forty-one patients with neurological impairments.

OUTCOMES AND MEASURES

The ScanCourse (participants identify numbered cards placed on both sides of a hallway at various heights during locomotion).

RESULTS

The ScanCourse was found to have excellent interrater reliability (intraclass correlation coefficient [ICC] [1,1] = .998; 95% confidence interval [CI] [.996-.999]), test-retest reliability (ICC [1,1] = .912; 95% CI [.811-.959]), a high level of agreement, and a low standard error of measurement (.503), and it was found to be significantly correlated with Trails A (r_s = -.436, p = .009) and B (r_s = -.364, p = .029).

CONCLUSIONS AND RELEVANCE

The assessment was found to have strong measurement properties, and it is therefore an appropriate tool for assessing dual-task visual scanning among those with neurological impairments.

WHAT THIS ARTICLE ADDS

This research demonstrates that the ScanCourse is reliable between raters and over time and that scores on the measure vary as anticipated with scores on a related measure, which provides evidence of its validity. These findings support its use in practice.

Dual-Task Exercise Reduces Cognitive-Motor Interference in Walking and Falls After Stroke

Background and Purpose- Functional community ambulation requires the ability to perform mobility and cognitive task simultaneously (dual-tasking). This single-blinded randomized controlled study aimed to examine the effects of dual-task exercise in chronic stroke patients. Methods- Eighty-four chronic stroke patients (24 women; age, 61.2±6.4 years; time since stroke onset, 75.3±64.9 months) with mild to moderate motor impairment (Chedoke-McMaster leg motor score: median, 5; interquartile range, 4-6) were randomly allocated to the dual-task balance/mobility training group, single-task balance/mobility group, or upper-limb exercise (control) group. Each group exercised for three 60-minute sessions per week for 8 weeks. The dual-task interference effect was measured for the time to completion of 3 mobility tests (forward walking, timed-up-and-go, and obstacle crossing) and for the correct response rate during serial-3-subtractions and verbal fluency task. Secondary outcomes included the Activities-specific Balance Confidence Scale, Frenchay Activities Index, and Stroke-specific Quality of Life Scale. The above outcomes were measured at baseline, immediately after, and 8 weeks after training. Fall incidence was recorded for a 6-month period posttraining. Results- Only the dual-task group exhibited reduced dual-task interference in walking time posttraining (forward walking combined with verbal fluency [9.5%, P=0.014], forward walking with serial-3-subtractions [9.6%, P=0.035], and the timed-up-and-go with verbal fluency [16.8%, P=0.001]). The improvements in dual-task walking were largely maintained at the 8-week follow-up. The dual-task cognitive performance showed no significant changes. The dual-task program reduced the risk of falls and injurious falls by 25.0% (95% CI, 3.1%-46.9%; P=0.037) and 22.2% (95% CI, 4.0%-38.4%; P=0.023), respectively, during the 6-month follow-up period compared with controls. There was no significant effect on other secondary outcomes ( P>0.05). Conclusions- The dual-task program was effective in improving dual-task mobility, reducing falls and fall-related injuries in ambulatory chronic stroke patients with intact cognition. It had no significant effect on activity participation or quality of life. Clinical trial registration- URL: https://www.clinicaltrials.gov . Unique identifier: NCT02270398.

Gait as predictor of physical function in axial spondyloarthritis: the prospective longitudinal FOLOMI (Function, Locomotion, Measurement, Inflammation) study protocol

Axial spondyloarthritis (axSpA) is a chronic inflammatory rheumatic disease affecting predominantly sacroiliac joints and axial skeleton. axSpA progression being irregular and hardly predictable, identifying functional decline is particularly important in patient with axSpA to allow delivery of timely and targeted interventions. Pain, reduced range of motion or altered posture can have adverse consequences on gait. Although gait has previously been used as a sensitive measure of physical outcomes in elderly and pathological populations, to the best of our knowledge, no study has used gait as a predictor of physical function in patients with axSpA. The objective of our study is hence to determine if gait parameters measured in patients with axSpA could predict the evaluation at 18 months of physical function as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI). This is a prospective and longitudinal study. Sixty patients with axSpA and 30 healthy age- and sex-matched controls will be included. Patients should be aged 18-65 years at time of their first evaluation, followed at Grenoble Alpes University Hospital for axSpA or ankylosing spondylitis, able to walk 180 m without technical help and with stable treatment for at least 12 months. Clinical characteristics, BASFI, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), clinical and laboratory measurements of gait will be assessed during four visits (at baseline and at months 6, 12, and 18). Similar assessments will be performed once for the healthy control group. A linear mixed model at 6, 12 and 18 months will be constructed to answer to the first objective, with the BASFI as dependent variable and gait parameters as explanatory variables. The data collection started in August 2018 and will be completed with the inclusion and follow-up of all the participants. We believe that the combination of clinical and laboratory measurements of gait in patients with axSpA could strengthen the capacity to monitor disease's evolution and to predict changes in patients' physical function. Results of the present study could ultimately allow delivering targeted, timely, personalized interventions and treatment in patients with axSpA.Trial registration: The study was approved by local ethic committee (CPP Ile De France 1, RCB: 2017-A03468-45, date of agreement: July 17th, last version: V4.0, 2018, March 5th, 2019) and is retrospectively registered in Clinical trials (NCT03761212).

Test-Retest Reliability of Cognitive-Motor Interference Assessments in Walking With Various Task Complexities in Persons With Multiple Sclerosis

Background. Simultaneous execution of motor and cognitive tasks can result in worsened performance on one or both tasks, indicating cognitive-motor interference (CMI). A growing amount of research on CMI in persons with multiple sclerosis (pwMS) is observed. However, psychometric properties of dual-task outcomes have been scarcely reported. Objective. To investigate the between-day test-retest reliability of the motor and cognitive dual-task costs (DTCs) during multiple CMI test conditions with various task complexities in pwMS and matched healthy controls (HCs). Methods. A total of 34 pwMS (Expanded Disability Status Scale score 3.0 ± 0.8) and 31 HCs were tested and retested on 3 single cognitive, 4 single motor, and 12 cognitive-motor dual tasks. Cognitive tasks included serial subtraction by 7, titrated digit span backward, and auditory vigilance. Motor tasks were walking at self-selected speed, over obstacles, crisscross, and while carrying a water-filled cup. Outcome measures were cognitive and motor DTC, calculated as percentage change of dual-task performance compared with single-task performance. Intraclass correlations (ICCs) and Spearman correlation coefficients were calculated as appropriate. Results. For DTCmotor of gait speed, ICCs ranged from 0.45 to 0.81 and Spearman correlations from 0.74 to 0.82. For DTCcognitive, ICCs ranged from −0.18 to 0.49 and Spearman correlations from −0.28 to 0.26. Reliability depended on the type of motor and cognitive task. Conclusion. Reliability of the DTCmotor was, overall, good, whereas that of the DTCcognitive was poor. The “walking” and “cup” dual-task conditions were the most reliable regardless of the integrated cognitive task.

Cognitive-motor interference in walking after stroke: test–retest reliability and validity of dual-task walking assessments

Objective:

To explore the reliability and validity of a series of dual-task mobility assessments among individuals post-stroke.

Design:

Observational study with repeated measures.

Setting:

University laboratory.

Participants:

Thirty community-dwelling individuals with chronic stroke.

Interventions:

Not applicable.

Main Measures:

Each of the two mobility tasks (1-minute level-ground walking with and without obstacle-negotiation) was performed concurrently with each of the eight cognitive tasks (auditory Stroop test, serial subtraction, shopping list recall and category naming at two difficulty levels). Walking distance and obstacle hitting rate (OHR) indicated dual-task mobility performance. Number of correct responses (NCR) indicated cognitive performance. Reaction time was additionally measured for the auditory Stroop test. Construct validity was examined by correlations between the dual-task assessments. The dual-task assessments were repeated within 7–14 days for test–retest reliability.

Results:

Excellent test–retest reliability in walking distance and OHR was found (intraclass correlation coefficient, ICC(3,1) = 0.891–0.984, P < 0.05). Moderate to excellent reliability was found in NCR and reaction time (ICC(3,1) = 0.480–0.911, P < 0.01). Correlations between walking distance were excellent ( rs = 0.840–0.985, P < 0.01). Correlations of NCR and reaction time between low- and high-level cognitive tasks were mostly moderate to excellent ( rs  = 0.515–0.793, P < 0.01). Generally no significant correlations were found in NCR between the dual-task assessments with different cognitive domains.

Conclusion:

The dual-task walking assessments are reliable and valid for evaluating cognitive-motor interference in community-dwelling individuals post-stroke. The lack of correlations between the tasks of different cognitive domains indicates the need of using different cognitive domains in dual-task walking assessment post-stroke.

Evaluating the Measurement Properties of the ScanCourse, a Dual-Task Assessment of Visual Scanning

IMPORTANCE

The ScanCourse is used by occupational therapists to evaluate visual scanning ability during locomotion. Its measurement properties have not been examined.

OBJECTIVE

To assess the interrater reliability, test-retest reliability, and construct validity of the ScanCourse.

DESIGN

This study involved data collection at two time points. To assess test-retest reliability, the ScanCourse was administered twice within a 2-week period. To assess interrater reliability, a second rater was present for one session. To assess level of agreement, a Bland-Altman plot was created. To assess absolute reliability, the standard error of measurement was calculated. To evaluate construct validity, the results of the ScanCourse were compared with results of the Bells Test and Trail Making Test A and B.

SETTING

Rehabilitation hospital.

PARTICIPANTS

Forty-one patients with neurological impairments. Outcomes and Measures: The ScanCourse (participants identify numbered cards placed on both sides of a hallway at various heights during locomotion).

RESULTS

The ScanCourse was found to have excellent interrater reliability (intraclass correlation coefficient [ICC] [1,1] = .998; 95% confidence interval [CI] [.996-.999]), test-retest reliability (ICC [1,1] = .912; 95% CI [.811-.959]), a high level of agreement, and a low standard error of measurement (.503), and it was found to be significantly correlated with Trails A (rs = -.436, p = .009) and B (rs = -.364, p = .029).

CONCLUSIONS AND RELEVANCE

The assessment was found to have strong measurement properties, and it is therefore an appropriate tool for assessing dual-task visual scanning among those with neurological impairments. What This Article Adds: This research demonstrates that the ScanCourse is reliable between raters and over time and that scores on the measure vary as anticipated with scores on a related measure, which provides evidence of its validity. These findings support its use in practice.

A randomized controlled trial of a walking training with simultaneous cognitive demand (dual-task) in chronic stroke

BACKGROUND AND PURPOSE

The aim was to evaluate the tolerability of, adherence to and efficacy of a community walking training programme with simultaneous cognitive demand (dual-task) compared to a control walking training programme without cognitive distraction.

METHODS

Adult stroke survivors at least 6 months after stroke with a visibly obvious gait abnormality or reduced 2-min walk distance were included in a two-arm parallel randomized controlled trial of complex intervention with blinded assessments. Participants received a 10 week, bi-weekly, 30 min treadmill programme at an aerobic training intensity (55%-85% heart rate maximum), either with or without simultaneous cognitive demands. Outcome was measured at 0, 11 and 22 weeks. The primary assessment involved 2-min walk tests with and without cognitive distraction to investigate the dual-task effect on walking and cognition; secondary results were the Short Form Health Survey 36, EuroQol-5D-5L, the Physical Activity Scale for the Elderly (PASE) and step activity.

RESULTS

Fifty stroke patients were included; 43 received allocated training and 45 completed all assessments. The experimental group (n = 26) increased their mean (SD) 2-min walking distance from 90.7 (8.2) to 103.5 (8.2) m, compared with 86.7 (8.5) to 92.8 (8.6) m in the control group, and their PASE score from 74.3 (9.1) to 89.9 (9.4), compared with 94.7 (9.4) to 77.3 (9.9) in the control group. Statistically, only the change in the PASE differed between the groups (P = 0.029), with the dual-task group improving more. There were no differences in other measures.

CONCLUSIONS

Walking with specific additional cognitive distraction (dual-task training) might increase activity more over 12 weeks, but the data are not conclusive.

The Effects of Dual-Task Training on Patient Outcomes of Institutionalized Elderly Having Chronic Stroke

Background/Aims

The purpose of our study was to investigate the effects of dual-task training on balance, mobility, functional independence, and fear of falling in geriatrics with chronic stroke.

Methods

Fifty-three geriatrics diagnosed with stroke were included in our study. The elderly were divided into 2 groups, i.e., those walking with (intervention group, n = 25) and those walking without (controls, n = 28) dual-task training.

Results

We found statistically significant improvements in all parameters between pre- and posttreatment in both groups (p < 0.05).

Conclusion

Based on our findings, walking with dual-task training can be used in addition to conventional stroke rehabilitation aiming to improve balance and mobility.

The Cone Evasion Walk test: Reliability and validity in acute stroke

OBJECTIVE

To estimate the reliability and validity of the Cone Evasion Walk test (CEW), a new test assessing the ability to evade obstacles, in people with acute stroke.

METHODS

To estimate the reliability of the CEW, video recordings of 20 people with acute stroke performing the test were assessed by 10 physiotherapists on two occasions, resulting in a total of 400 ratings. Patients performed the CEW (n = 221), functional ambulation classification (FAC; n = 204), Timed Up and Go (TUG; n = 173), TUG cognitive (TUG-cog; n = 139), Serial 7s attention task from the Montreal Cognitive Assessment (MoCA-S7; n = 127), and the Star Cancellation Test (SCT; n = 151). These tests and side of lesion (n = 143) were used to examine construct validity. The predictive validity was evaluated in relation to falls during the following 6 months (n = 203).

RESULTS

The intraclass correlation coefficients for intrarater and interrater reliability were 0.88-0.98. For validity, there were significant correlations between the CEW and FAC (r_s  = -0.67), TUG (r_s  = 0.45), MoCA-S7 (r_s  = -0.36), and SCT total score (r_s  = -0.36). There was a significant correlation between the number of cones touched on the left side and the proportion of cancelled stars on the left (r_s  = -0.23) and right (r_s  = 0.23) side in the SCT. Among right hemisphere stroke participants (n = 79), significantly more persons hit cones on the left side (n = 25) than the right side (n = 8), whereas among those with a left hemisphere stroke (n = 64) significantly more persons hit cones on the right side (n = 11) than the left (n = 3). Cox regression showed that participants who touched four to eight cones had an increased risk of falls over time (hazard ratio 2.11, 95% CI [1.07, 4.17]) compared with those who touched none.

CONCLUSION

The new CEW test was reliable and valid in assessing the ability to evade obstacles while walking and to predict falls in patients with acute stroke.

Over-focused? The relation between patients' inclination for conscious control and single- and dual-task motor performance after stroke

BACKGROUND

Many stroke patients are inclined to consciously control their movements. This is thought to negatively affect patients' motor performance, as it disrupts movement automaticity. However, it has also been argued that conscious control may sometimes benefit motor performance, depending on the task or patientś motor or cognitive capacity.

AIM

To assess whether stroke patients' inclination for conscious control is associated with motor performance, and explore whether the putative association differs as a function of task (single- vs dual) or patientś motor and cognitive capacity.

METHODS

Univariate and multivariate linear regression analysis were used to assess associations between patients' disposition to conscious control (i.e., Conscious Motor Processing subscale of Movement-Specific Reinvestment Scale; MSRS-CMP) and single-task (Timed-up-and-go test; TuG) and motor dual-task costs (TuG while tone counting; motor DTC%). We determined whether these associations were influenced by patients' walking speed (i.e., 10-m-walk test) and cognitive capacity (i.e., working memory, attention, executive function).

RESULTS

Seventy-eight clinical stroke patients (<6 months post-stroke) participated. Patients' conscious control inclination was not associated with single-task TuG performance. However, patients with a strong inclination for conscious control showed higher motor DTC%. These associations were irrespective of patients' motor and cognitive abilities.

CONCLUSION

Patients' disposition for conscious control was not associated with single task motor performance, but was associated with higher motor dual task costs, regardless of patients' motor or cognitive abilities.

CLINICAL RELEVANCE

Therapists should be aware that patients' conscious control inclination can influence their dual-task performance while moving. Longitudinal studies are required to test whether reducing patients' disposition for conscious control would improve dual-tasking post-stroke.

Dual-task training effects on motor and cognitive functional abilities in individuals with stroke: a systematic review

Objective:

This systematic review aimed to examine the effects of dual-task balance and mobility training in people with stroke.

Methods:

An extensive electronic databases literature search was conducted using MEDLINE, PubMed, EBSCO, The Cochrane Library, Web of Science, SCOPUS, and Wiley Online Library. Randomized controlled studies that assessed the effects of dual-task training in stroke patients were included for the review (last search in December 2017). The methodological quality was evaluated using the Cochrane Collaboration recommendation, and level of evidence was determined according to the criteria described by the Oxford Center for Evidence-Based Medicine.

Results:

About 13 articles involving 457 participants were included in this systematic review. All had substantial risk of bias and thus provided level IIb evidence only. Dual-task mobility training was found to induce more improvement in single-task walking function (standardized effect size = 0.14–2.24), when compared with single-task mobility training. Its effect on dual-task walking function was not consistent. Cognitive-motor balance training was effective in improving single-task balance function (standardized effect size = 0.27–1.82), but its effect on dual-task balance ability was not studied. The beneficial effect of dual-task training on cognitive function was provided by one study only and thus inconclusive.

Conclusion:

There is some evidence that dual-task training can improve single-task walking and balance function in individuals with stroke. However, any firm recommendation cannot be made due to the weak methodology of the studies reviewed.

Age-related decrements in dual-task performance: Comparison of different mobility and cognitive tasks. A cross sectional study

This cross-sectional study investigated the age-related differences in dual-task performance both in mobility and cognitive tasks and the additive dual-task costs in a sample of older, middle-aged and young adults. 74 older adults (M = 72.63±5.57 years), 58 middle-aged adults (M = 46.69±4.68 years) and 63 young adults (M = 25.34±3.00 years) participated in the study. Participants performed different mobility and subtraction tasks under both single- and dual-task conditions. Linear regressions, repeated-measures and one-way analyses of covariance were used, The results showed: significant effects of the age on the dual and mobility tasks (p<0.05) and differences among the age-groups in the combined dual-task costs (p<0.05); significant decreases in mobility performance under dual-task conditions in all groups (p<0.05) and a decrease in cognitive performance in the older group (p<0.05). Dual-task activity affected mobility and cognitive performance, especially in older adults who showed a higher dual-task cost, suggesting that dual-tasks activities are affected by the age and consequently also mobility and cognitive tasks are negatively influenced.

Psychometric properties of dual-task balance and walking assessments for individuals with neurological conditions: A systematic review

BACKGROUND

The ability of performing a balance or walking task in conjunction with a secondary cognitive or motor task, referred to as dual-task (DT) ability, is essential in daily living. While there is some evidence that DT performance is impaired in individuals with neurological conditions, using reliable and valid tools to measure DT performance is essential. This systematic review aimed to evaluate the psychometric properties of DT balance and walking assessments in individuals with different neurological conditions.

METHODS

A systematic literature search was conducted using PubMed, CINAHL, MEDLINE, PsycINFO, SCOPUS, Web of Science, and Cochrane Library (last search done in April 2016). The methodological quality was rated using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist.

RESULTS

Twenty-three articles involving individuals with stroke, Parkinson's disease, mild cognitive impairment, dementia, Alzheimer's disease, and multiple sclerosis were included. Outcomes derived from the walking tasks under DT condition generally demonstrated good reliability (correlation coefficient ≥0.75) across different neurological disorders, but their usefulness in distinguishing fallers from non-fallers was inconclusive. The reliability of outcomes derived from the cognitive/motor tasks and from the dual-task effect (DTE) (i.e., DT performance minus single-task performance) seemed to be lower but was understudied. The reliability of static or dynamic sitting/standing balance outcomes in DT condition was not assessed in any of the selected studies.

CONCLUSIONS

The reliability of the outcomes derived from walking tasks was good. The psychometric properties of other DT outcomes need to be further investigated.

Walking adaptability therapy after stroke: study protocol for a randomized controlled trial

BACKGROUND

Walking in everyday life requires the ability to adapt walking to the environment. This adaptability is often impaired after stroke, and this might contribute to the increased fall risk after stroke. To improve safe community ambulation, walking adaptability training might be beneficial after stroke. This study is designed to compare the effects of two interventions for improving walking speed and walking adaptability: treadmill-based C-Mill therapy (therapy with augmented reality) and the overground FALLS program (a conventional therapy program). We hypothesize that C-Mill therapy will result in better outcomes than the FALLS program, owing to its expected greater amount of walking practice.

METHODS

This is a single-center parallel group randomized controlled trial with pre-intervention, post-intervention, retention, and follow-up tests. Forty persons after stroke (≥3 months) with deficits in walking or balance will be included. Participants will be randomly allocated to either C-Mill therapy or the overground FALLS program for 5 weeks. Both interventions will incorporate practice of walking adaptability and will be matched in terms of frequency, duration, and therapist attention. Walking speed, as determined by the 10 Meter Walking Test, will be the primary outcome measure. Secondary outcome measures will pertain to walking adaptability (10 Meter Walking Test with context or cognitive dual-task and Interactive Walkway assessments). Furthermore, commonly used clinical measures to determine walking ability (Timed Up-and-Go test), walking independence (Functional Ambulation Category), balance (Berg Balance Scale), and balance confidence (Activities-specific Balance Confidence scale) will be used, as well as a complementary set of walking-related assessments. The amount of walking practice (the number of steps taken per session) will be registered using the treadmill's inbuilt step counter (C-Mill therapy) and video recordings (FALLS program). This process measure will be compared between the two interventions.

DISCUSSION

This study will assess the effects of treadmill-based C-Mill therapy compared with the overground FALLS program and thereby the relative importance of the amount of walking practice as a key aspect of effective intervention programs directed at improving walking speed and walking adaptability after stroke.

TRIAL REGISTRATION

Netherlands Trial Register NTR4030 . Registered on 11 June 2013, amendment filed on 17 June 2016.