Supervised and Self-Directed Technology-Based Dual-Task Exercise Training Program for Older Adults With a History of Falls: Mixed Methods Feasibility Study

Abstract: Background: In this study, Parkinson's disease patients underwent evaluation of gait velocity and balance concerning Integrated dual task training (IDTT) and Consecutive dual task (CDTT) training. The Berg Balance Scale and 10-meter Walk Test (10MWT) were utilized for assessment. Participants were randomly assigned to either Integrated dual task training (IDTT) or Consecutive dual task training (CDTT) groups based on pre-test results. Post-test evaluations aimed to measure improvements in balance and gait velocity. This research explores innovative methods of rehabilitation using both the dual task training, offering promising guidelines for future therapeutic approaches. Objective: To compare the effect of Integrated dual task training (IDTT) and Consecutive dual task training (CDTT) on balance and gait velocity among Parkinson’s disease patients. Methods: Subjects diagnosed with Parkinson's disease underwent assessment of motor symptoms, functional mobility, and balance. Pre-tests using the Berg Balance Scale and 10MWT were conducted to gather baseline data. Participants were randomly divided into Integrated dual task training (IDTT) or Consecutive dual task (CDTT) training groups, with treatment occurring four days a week for eight weeks. Pre- and post-test assessments measured outcomes using the 10MWT and Berg Balance Scale and effectiveness of intervention was evaluated. Results: The study revealed significant improvements in gait velocity and balance following IDTT. Statistical analysis indicated a notable difference between pre- and post-test measurements. Conclusion: Based on the study results, it can be concluded that IDTT significantly improves balance and gait in people with Parkinson's disease. Keywords: Parkinson's disease, dual task, gait velocity, balance.

Background: Dual tasks fall into two main groups: motor dual tasks, which require performance of a motor task and a postural control task at the same time; and cognition dual task that require performance of a cognition task and postural control task at the same time. Aim: To focus on comparative effects of motor and cognitive dual-task gait training on balance and mobility in persons with intellectual disabilities Methodology: A randomized clinical trial was conducted on 52 subjects (n=26) in a District Headquarter Hospital, Mirpur AJK. Fifty-two patients were randomly allocated in two groups as Group A received motor dual task and Group B received cognitive dual task training. Total duration of study was three weeks and assessment done before treatment and after every week. Rancho Los Amigos Cognitive Functional Scale (RLACF), Berg Balance Scale (BBS), Walking While Talking Test (WWT) and Stair Climb Test (SCT) for the assessment of the patient’s improvement in skills, balance and mobility. Results: The results of the study concluded that Rancho Los Amigos Cognitive Function Scale, Berg Balance Scale, Walking While Talking Test and Stair Climb Test scores were improved in both groups significantly. But on comparison; Cognitive dual task training significantly produce better results in improving the balance and mobility in the person with intellectual disability as compared to Motor dual task training with p value<0.005. Conclusion: The study concluded that Cognitive dual task training is statistically and clinically more significant in improving the balance and mobility in the intellectual disable persons as compared to Motor dual task training. Key words: Cognitive dual task, Intellectual disabilities, Motor and cognitive dual-task gait training.

Effects of Dual Task Training on Dual Task Gait Performance and Cognitive Function in Individuals With Parkinson Disease: A Meta-analysis and Meta-regression

BackgroundDual 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.ObjectiveTo 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.MethodsCMI-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]).ResultsThe 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.ConclusionsCMI-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.

The use of dual-task training paradigm to enhance postural stability in patients with balance impairments is an emerging area of interest. The differential effects of dual tasks and dual-task training on postural stability still remain unclear. A systematic review and meta-analysis were conducted to analyze the effects of dual task and training application on static and dynamic postural stability among various population groups. Systematic identification of published literature was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, from inception until June 2016, on the online databases Scopus, PEDro, MEDLINE, EMBASE, and SportDiscus. Experimental studies analyzing the effects of dual task and dual-task training on postural stability were extracted, critically appraised using PEDro scale, and then summarized according to modified PEDro level of evidence. Of 1,284 records, 42 studies involving 1,480 participants met the review’s inclusion criteria. Of the studies evaluating the effects of dual-task training on postural stability, 87.5% of the studies reported significant enhancements, whereas 30% of the studies evaluating acute effects of dual tasks on posture reported significant enhancements, 50% reported significant decrements, and 20% reported no effects. Meta-analysis of the pooled studies revealed moderate but significant enhancements of dual-task training in elderly participants (95% CI: 1.16–2.10) and in patients suffering from chronic stroke (−0.22 to 0.86). The adverse effects of complexity of dual tasks on postural stability were also revealed among patients with multiple sclerosis (−0.74 to 0.05). The review also discusses the significance of verbalization in a dual-task setting for increasing cognitive–motor interference. Clinical implications are discussed with respect to practical applications in rehabilitation settings.

Dual-task (DT) training, which involves the simultaneous execution of cognitive and motor tasks, has been shown to influence task performance and cortical activation, yet evidence on the effects of DT training and cortical activation for complex postural control tasks remains limited. This study investigated the immediate and retention effects of a one-week DT training program on DT learning, performance in DT and single-task conditions, and activation in bilateral prefrontal (PFC) and vestibular cortices in healthy young adults. Eighteen individuals (age = 22.39 ± 1.73 years) participated in the study. The DT paradigm involved a dynamic stability platform (motor task) paired with either a simple or complex auditory reaction time (RT) task (cognitive). Participants completed 20-25 minutes of DT training (18 trials/day) across five consecutive days. DT performance was measured by the duration participants maintained the stability platform within 3 degrees of the horizontal while responding to auditory stimuli. Single-task motor and cognitive performances were also assessed. Cortical activation in the PFC and vestibular cortices was measured using functional near infrared spectroscopy (fNIRS), tracking changes in oxygenated hemoglobin (HbO) concentrations. Pre-training, post-training, and one-week follow-up testing was conducted. The results demonstrate that DT training significantly improves and retains DT performance, likely due to a reduction in cognitive-motor interference. Additionally, DT training led to decreased activation in the bilateral PFC and vestibular cortices, specifically for complex DT condition, suggesting enhanced attentional resource allocation and optimized vestibular input processing, indicative of neural efficiency. Notably, these training effects also transferred to single-task cognitive and motor performances, with corresponding reductions in PFC and vestibular cortex activation, despite the lack of direct training on these tasks. This study advances our understanding of the neural mechanisms underlying DT training and underscores the critical role of practice in optimizing cognitive-motor efficiency.

Aim. To assess the effects of cognitive rehabilitation with dual-task training that involves a cognitive task combined with postural and walking control, as well as electroencephalogram indices in patients in the early postoperative period after direct myocardial revascularization.Methods. The study enrolled 48 patients scheduled for coronary artery bypass graft surgery. Subjects in this prospective, randomized study were randomized using envelopes to a postoperative cognitive training group (n = 23) and non-training group (n = 25). The cognitive training was carried out daily, starting 3-4 days after the procedure and until the discharge order. Dual tasks training (a cognitive task combined with postural and walking control) lasted 15-20 minutes. All patients were submitted to an extended neurophysiological assessment (psychometric tests and electroencephalogram study) and stabilography 3-5 days before and 8-11 days after coronary artery bypass grafting.Results. The patients who underwent cognitive training experienced postoperative cognitive dysfunction (POCD) in 39% cases in the early postoperative period after intervention, while the non-training group - in 64%. The relative risk of developing POCD in the non-training group was 2.77 (95% CI: 0.86-8.91, Z = 1.704, p = 0.08). The patients in cognitive training exhibited better cognitive state compared to the preoperative state (Z = 2.58; p = 0.01) in the absence of statistically significant differences in the non-training group. Moreover, type-1 theta power values increased in the non-training group in comparison to the preoperative values, while the cognitive training group did not have a statistically significant difference in theta power.Conclusion. Positive effects of dual task rehabilitation on the neurophysiological parameters of patients undergoing direct myocardial revascularization were demonstrated. Positive effects include lower frequency of POCD, improved cognitive state and less pronounced cortical dysfunction. The dual task training had proved a suitable training method for this category of patients. Additional studies are required to test the possibility of increasing the duration and intensity of dual task training for stronger recovery effect and improved cognitive and walking performance of patients in the postoperative period after direct myocardial revascularization.

Falls among older adults pose a significant public health challenge, as they lead to severe outcomes such as fractures and loss of independence. Research has shown that training cognitive function and balance simultaneously, termed Dual-Task (DT) training, improves mobility and reduces fall risks in older adults. This study aims to evaluate the feasibility and acceptability of a blended supervised and self-directed technology-based DT training programme for older adults who have high risk of falling. This is a single-arm, non-randomised feasibility study employing quantitative and qualitative methods. Fifty healthy adults aged 65 years or above will be recruited from the NHS primary and secondary care pathways and from the community. Participants will undergo supervised cognitive and balance DT training for 12 weeks, followed by self-directed DT training for an additional 12 weeks. The cognitive training will be delivered using a commercial mobile application (app) available from the AppStore or Google Play. The balance training will involve static (Marching on the spot, Tandem Stand, Hip Abduction & Extension, Squats, Tiptoe Stand, and Pendulum/Sideways Sway) and dynamic (Figure of Eight Walk, Walking Forwards and Backwards, Lunges, Functional Reach, Toe Tapping, Upper Limb Strength Exercises, and Side-Steps/Simple Grapevine) exercises focused on improving balance, postural stability and strength. Feasibility outcomes will be recruitment, adherence, usage of the app, and attrition. Outcomes measure data, that will be collected at baseline and at 24 weeks, includes the Timed- Up and Go (TUG) test (likely primary outcome in any future trial), along with self-reported questionnaires assessing cognition, fear of falling, quality of life, healthcare service usage, and the self-reported number of falls. Focus group interviews will be conducted with thirty participants and thirty healthcare professionals for in-depth exploration of the feasibility and acceptability of the DT training programme.

This study aims to compare the effects of single-task and dual-task training on balance performance in elderly patients with knee osteoarthritis (OA). Fifty elderly osteoarthritic patients with balance impairment (16 males, 34 females; mean age 72.9±5.5 years; range 65 to 84 years) were included in this study. Patients were randomly assigned to single-task balance training (group 1) or dual-task balance training (group 2) groups. Balance activities were given to both groups for three times a week for four weeks. Patients in group 2 also performed cognitive tasks simultaneously with these exercises. Patients were evaluated with Berg balance scale (BBS), kinesthetic ability trainer static and dynamic scores, timed up and go (TUG) test and walking speed (WS) for single and dual tasks, number of stopping and activities-specific balance confidence (ABC) scale at baseline and at the end of four weeks. At the end of the therapy, there were statistically significant improvements in BBS, KAT 2000 static and dynamic scores, TUG test and WS for single and dual tasks, number of stopping and ABC scale in both groups (p<0.05). But there was no statistical difference in any parameter between the groups (p>0.05). Both single- and dual-task trainings are effective in improving balance performance under single- and dual-task conditions in elderly patients with knee OA. Dual-task training is not superior to single-task training for balance improvement in elderly osteoarthritic patients.

Dual task (DT) training is becoming prominent in fall prevention. However, DT training should include task-managing strategies like task switching or task prioritization to be beneficial to improve gait performance under DT conditions. The aim of this pilot study was to evaluate the effect of a task managing training on gait stability. A DT training (12 sessions; 60 min each; 12 weeks) was compared to a non-training control group within a RCT (38 independent living participants; 72.7 ± 4.7 years). Single Task (ST) and DT walking (visual verbal Stroop task) were measured on a treadmill (FDM-T, 3.5 km/h, 100 HZ). Gait parameters like step length, step width, gait line, maximum forces and gait variability were compared. The training group improved their gait performance under ST and DT conditions as revealed by significant group×time interaction effects. The training successfully improved gait performance and therefore might be a promising approach to prevent falls. Additional fall prevention studies should focus on motor-cognitive performance and reinforce outcomes of task managing strategies.

Effects of cognitive-motor dual task training on cognitive and physical performance in healthy children and adolescents: A scoping review

Background: Physiotherapeutic interventions play a crucial role in motor re-learning and functional recovery for stroke patients with upper and lower limb motor impairments. Among these interventions, dual-task training (DTT) has demonstrated significant effectiveness in enhancing the functional recovery of stroke patients. Objective: This study aims to compare the effectiveness of DTT and conventional physical therapy in ambulating right-hemiplegic stroke patients.Material and Methods: A randomized control trial (RCT) was conducted at the Department of Rehabilitation Medicine, Saidu group of Teaching Hospital, 2nd March 2020 to 3rd August 2020. Chronic right-hemiplegic stroke patients meeting set inclusion criteria were randomly assigned to two groups: the treatment group (TG) receiving DTT and the control group (CG) undergoing conventional physical therapy. DTT interventions included walking forward, backward, and sideways on a smooth surface while holding an 80-gram sandbag. The CG received conventional physiotherapy involving mat activities, strengthening, stretching exercises, and ambulation/gait training. Pre- and post-tests collected clinical data analyzed on SPSS 22 included spatial and temporal variables, 10-Meter Walk Test (10MWT), Time Up &amp; Go Test (TUG), step length, cadence, cycle time, and stride length. Results: Out of 18 patients, each group had 50%, comprising 5 males (28%) and 4 females (22%). The mean age in CG was 57.20± 5.20, and in TG, it was 57.27± 6.10 years. Baseline clinical parameters were nearly identical between groups (P&gt;0.05). Post-test scores revealed significant improvements in spatial and temporal gait variables, 10MWT score, cadence, step length, stride, and cycle time in TG compared to CG (P&lt;0.05). Conclusion: Dual-task training and conventional physical therapy both significantly enhance the functional ability of right-hemiplegic patients across all gait temporal and spatial parameters. Keywords: Conventional physical therapy, Dual task training, Gait &amp; ambulation, Stroke.

Research background. It was found that dual task training improves functional abilities in subjects with neurological disorders, however it is not known how dual task training affects balance and functional mobility in children with cerebral palsy (CP).The aim. To determine the effectiveness of dual motor tasks training and basic physiotherapy programme on balance and functional mobility in children with spastic diplegic CP.Methods. The study included 20 children with spastic diplegic CP. Subjects were randomly assigned into two groups: control group (40 min basic physiotherapy programme) and experimental group (20 min basic physiotherapy programme and 20 min dual motor task training). Physiotherapy was applied for 3 weeks (5 times a week). Balance and functional mobility were assessed at baseline and at the end.Results. There was a statistically significant improvement in balance and functional mobility in both the control and experimental groups after three weeks of physiotherapy (p &lt; 0.05). Comparing two groups with each other, there was a statistically significant improvement in the experimental group on balance and walking (p &lt; 0.05).Conclusion. Dual task training can be used as an effective intervention to improve balance and walking in children with spastic diplegic CP.Keywords: motor tasks, cerebral palsy, balance, functional mobility.

Motor-cognitive (dual-task) training may enhance functional recovery after total knee arthroplasty (TKA). However, evidence for itsintegration into telerehabilitation programs is limited. To investigate the effects of motor-cognitive dual-task training on physical and cognitive performance in older adults undergoing TKA. A randomized controlled trial was conducted with 28 older adults undergoing TKA. Participants were assigned to a control group (CG;n=14), which received routine physiotherapy via telerehabilitation following one face-to-face session, or an intervention group (IG; n=14), whichreceived the same protocol plus an 8-week motor-cognitive dual-task training program. Pre- and post-intervention assessments included VisualAnalogue Scale (VAS), Knee Society Score (KSS), Mini-Mental State Examination, Dual Task Questionnaire, cognitive Timed Up and Go Test(cTUG), Lower Extremity Motor Coordination Test (LEMOCOT), 3-Meter Backward Walk Test (3-MBWT), 10-Meter Walk Test (10-MWT), WalkingImpact Scale (WALK-12), and Reaction Time Test. The IG demonstrated significantly greater improvements in both rest and activity VAS scores (p<0.001). Both groups showedimprovement in 3-MBWT performance (p<0.001), with the IG exhibiting superior gains (p=0.019). The IG also demonstrated greater improvement incTUG (p<0.001) and LEMOCOT scores (p<0.001). No additional benefits of dual-task training were observed for KSS symptom scores, gaitparameters (10-MWT, WALK-12), reaction time, or cognitive outcomes. Integrating dual-task training into telerehabilitation following TKA yields superior improvements in pain, dual-task performance, andsomatosensory-motor function in older adults. However, dual-task-specific exercises do not provide additional benefits regarding knee symptoms,gait speed, reaction time, or global cognitive performance compared with standard physiotherapy alone.

Introduction The evidence for changes in intracortical inhibition when executing two tasks simultaneously (i.e., dual tasking) is ambiguous as decreased (Corp et al., 2014) and increased (Corp et al., 2016) inhibition were reported. One way to bring more light into this question is to tests the effect of a single task training (STT) and a dual task training (DTT) on the short interval intracortical inhibition (SICI) during a single balancing task and two different dual tasks in healthy young adults. Methods Twenty-nine healthy young adults were randomly separated into two groups participating in STT (n = 15) or DTT (n = 14) consisting of 6 training sessions within 3 weeks. Before and after the training, a single task (balancing on a rocker board) was performed at two resistance levels (easy and hard). Additionally to the single task, either a cognitive (2-back number recall) or a motor (balancing a ball on a hand-held tray) dual task was executed simultaneously. During execution of these three tasks, SICI was measured with transcranial magnetic stimulation over the motor cortical area representing the right tibialis anterior. Results Training improvements in balance performance were group and task-specific over time (p = .018). While the STT group improved more in the single balance task (12.3% vs. 6.6% DTT), the DTT group had more sway reductions in the motor dual task condition (13.7% vs. 4.5% STT). Similar statistical outcome (p = .034) was observed for the dual task costs (DTC). There was a tendence for SICI (p = .075), mainly indicating higher increase in SICI for the DTT group in the motor dual task (16.0% vs. 5.8% STT). During the execution of the single balance task, the group-specific adaptations in SICI were less pronounced (13.7% DTT vs. 16.2% STT). When analyzing the SICI dual task difference (Δ) from single to dual task, SICI is altered group and task specific (p = .011). The DTT group could increase the dual task difference in SICI in the dual motor condition (Δ 3.2%), whereas the STT group had a decrease (Δ -9.6%). Discussion/Conclusion The results of this study show that DTT causes gains in balance performance and increases in SICI when the secondary task is also a motor task, but not when the second task is a cognitive one. STT is particularly beneficial in the single task. It is therefore assumed that intracortical inhibition is important during the simultaneous performance of two motor tasks, while intracortical inhibition was not modulated in a group-specific manner by the additional cognitive task. References Corp, D. T., Lum, J. A. G., Tooley, G. A., &amp; Pearce, A. J. (2014). Corticospinal activity during dual tasking: A systematic review and meta-analysis of TMS literature from 1995 to 2013. Neuroscience &amp; Biobehavioral Reviews, 43, 74-87. https://doi.org/10.1016/j.neubiorev.2014.03.017 Corp, D. T., Rogers, M. A., Youssef, G. J., &amp; Pearce, A. J. (2016). The effect of dual-task difficulty on the inhibition of the motor cortex. Experimental Brain Research, 234, 443-452. https://doi.org/10.1007/s00221-015-4479-2