Effect of Explicit Prioritization on Dual Tasks During Standing and Walking in People With Neurologic and Neurocognitive Disorders: A Systematic Review and Meta-analysis

OBJECTIVES

To examine the effectiveness of explicit task (ie, equal, motor or cognitive) prioritization during dual tasking (DT) in adults with neurologic and neurocognitive disorders (stroke, Parkinson disease [PD], multiple sclerosis, dementia, Alzheimer disease, and mild cognitive impairment).

DATA SOURCE

A systematic search in 4 databases (PubMed, Web of Science, Embase, and Cochrane Central) yielded 1138 unique studies published up to 2023.

STUDY SELECTION

Forty-one experimental studies were selected that assessed the effect of explicit prioritization instructions on both motor and cognitive performance during dual-tasks related to standing and walking in selected populations. Primary outcome measures were walking speed and response accuracy. Availability of data allowed us to perform a meta-analysis on 27 of the 41 articles by using inverse variance with a random effects model.

DATA EXTRACTION

The data including design, subject characteristics, motor and cognitive tasks, prioritization, motor and cognitive outcomes, instructions, and key findings were extracted. Two assessors rated the selected studies for risk of bias and quality using the Quality Assessment Tools of the National Institutes of Health.

DATA SYNTHESIS

This study examined 1535 adults who were asked to perform motor-cognitive DT in standing or walking, including 381 adults with stroke, 526 with PD, 617 with multiple sclerosis, 10 with dementia, 9 with Alzheimer disease, and 8 with mild cognitive impairment. During all prioritization instructions, participants slowed down during DT (standardized mean difference (SMD)equal=0.43; SMDmotor=0.78; SMDcognitive=0.69, P<.03) while maintaining similar response accuracy (SMDequal=0.12; SMDmotor=0.23; SMDcognitive=-.01, P>.05). However, considerable between-group heterogeneity was observed resulting in different motor and cognitive responses between pathologies.

CONCLUSION

Motor prioritization was achieved in adults with PD and stroke, unlike adults with neurocognitive disorders who were negatively affected by any type DT prioritizing. The reported within-group heterogeneity revealed that effects of explicit task prioritization are dependent on motor and cognitive task complexity, and the type of instructions. Recommendations are provided to ensure accurate use of instructions during DT paradigms.

Power of instructions for task implementation: superiority of explicitly instructed over inferred rules

"Power of instructions" originally referred to automatic response activation associated with instructed rules, but previous examination of the power of instructed rules in actual task implementation has been limited. Typical tasks involve both explicit aspects (e.g., instructed stimulus-response mapping rules) and implied, yet easily inferred aspects (e.g., be ready, attend to error beeps) and it is unknown if inferred aspects also become readily executable like their explicitly instructed counterparts. In each mini-block of our paradigm we introduced a novel two-choice task. In the instructions phase, one stimulus was explicitly mapped to a response; whereas the other stimulus' response mapping had to be inferred. Results show that, in most cases, explicitly instructed rules were implemented more efficiently than inferred rules, but this advantage was observed only in the first trial following instructions (though not in the first implementation of the rules), which suggests that the entire task set was implemented in the first trial. Theoretical implications are discussed.

Using road markings as a continuous cue for speed choice

The potential for using road markings to indicate speed limits was investigated in a driving simulator over the course of two sessions. Two types of experimental road markings, an "Attentional" set designed to provide visually distinct cues to indicate speed limits of 60, 80 and 100 km/h, and a "Perceptual" set designed to also affect drivers' perception of speed, were compared to a standard undifferentiated set of markings. Participants (n = 20 per group) were assigned to one of four experimental groups (Attentional-Explicit, Attentional-Implicit, Perceptual-Explicit, Perceptual-Implicit) or a Control group (n = 22; standard road markings). The Explicit groups were instructed about the meaning of the road markings while those in the Implicit and Control groups did not receive any explanation. Participants drove five 10 km simulated roads containing three speed zones (60, 80 and 100 km/h) during the first session. The participants returned to the laboratory approximately 3 days later to drive five more trials including roads they had not seen before, a trial that included a secondary task, and a trial where speed signs were removed and only markings were present. The findings indicated that both types of road markings improved drivers' compliance with speed limits compared to the control group, but that explicit instruction as to the meaning of the markings was needed to realise their full benefit. Although previous research has indicated the benefit of road markings used as warnings to indicate speed reductions in advance of horizontal or vertical curves, the findings of the present experiment also suggest that systematically associating road markings with specific speed limits may be a useful way to improve speed limit compliance and increase speed homogeneity.