Dual-task Training in Chronic Stroke

Training Dual-task Balance and Walking in Community-dwelling Older Adults With Chronic Stroke: a Randomized Controlled Trial

Background Functional community ambulation not only requires a critical level of postural control and walking skills, but also the ability to engage in cognitive tasks while walking (i.e., dual-task walking) and adapt to the constantly-changing environmental contexts. There is evidence showed that dual-task balance and gait performance is significantly impaired after stroke. Increasing evidence also suggests that dual-task balance and gait performance is useful for predicting falls among individuals with stroke. Considering the high clinical relevance of dual-task balance and gait performance, it is essential that stroke rehabilitation adequately addresses dual-task deficits. Developing specific dual-task balance and gait training to enhance dual-task performance is thus necessary to promote community ambulation and reintegration.

Study Aim The aim of this Introduction Many individuals after stroke continue to cope with residual physical impairments after discharge from hospital. One of the major problems encountered by people after stroke is community reintegration. Functional community ambulation not only requires a critical level of postural control and walking skills, but also the ability to engage in cognitive tasks while walking (i.e., dual-task walking) and adapt to the constantly-changing environmental contexts. There has been an increasing awareness of the importance of dual-task gait performance in community-dwelling individuals with stroke in the past few years.

There is evidence showed that dual-task balance and gait performance is significantly impaired after stroke. Increasing evidence also suggests that dual-task balance and gait performance is useful for predicting falls among individuals with stroke. Considering the high clinical relevance of dual-task balance and gait performance, it is essential that stroke rehabilitation adequately addresses dual-task deficits. Developing specific dual-task balance and gait training to enhance dual-task performance is thus necessary to promote community ambulation and reintegration.

Study Aim This will be a single-blinded randomized controlled trial (RCT).The aim of this study is to examine the efficacy of a dual-task exercise program on cognitive-motor interference in balance and walking tasks, balance self-efficacy, participation in everyday activities, community reintegration and incidence of falls among individuals with chronic stroke.

Study Overview

• Status: Unknown
• Conditions: Stroke
• Intervention / Treatment: Behavioral: Dual-task training group; Behavioral: Single-task training group; Behavioral: Flexibility and strength training group

Detailed Description

Introduction Many individuals after stroke continue to cope with residual physical impairments after discharge from hospital. One of the major problems encountered by people after stroke is community reintegration. Functional community ambulation not only requires a critical level of postural control and walking skills, but also the ability to engage in cognitive tasks while walking (i.e., dual-task walking) and adapt to the constantly-changing environmental contexts. There has been an increasing awareness of the importance of dual-task gait performance in community-dwelling individuals with stroke in the past few years.

There is evidence showed that dual-task balance and gait performance is significantly impaired after stroke. Increasing evidence also suggests that dual-task balance and gait performance is useful for predicting falls among individuals with stroke. Considering the high clinical relevance of dual-task balance and gait performance, it is essential that stroke rehabilitation adequately addresses dual-task deficits. Developing specific dual-task balance and gait training to enhance dual-task performance is thus necessary to promote community ambulation and reintegration.

Study Aim The aim of this study is to examine the efficacy of a dual-task exercise program on cognitive-motor interference in balance and walking tasks, balance self-efficacy, participation in everyday activities, community reintegration and incidence of falls among individuals with chronic stroke.

Study design

This will be a single-blinded randomized controlled trial (RCT). After baseline evaluation, subjects will be randomly allocated to one of the three groups: (1) dual-task training group, (2) single-task training group, (3) strengthening and flexibility exercise group (controls), using a 1:1:1 randomization sequence.

Measurements Outcomes will be used to compare the therapeutic effects of the 3 treatment groups. The outcome measurements (except data on incidence of falls) will take place at 3 time points: (1) within one week before initiation of intervention (baseline), (2) within one week after completion of training, (3) 8 weeks after completion of training. The fall data will be collected on a monthly basis until 6 months after termination of the intervention period. All assessments will be performed by a researcher who is blinded to group allocation.

• Study Type: Interventional
• Enrollment (Anticipated): 84
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Hong Kong
  • Hung Hom, Hong Kong
    • Recruiting
    • Hong Kong Polytechnic University
    • Principal Investigator: Marco YC Pang, PhD
    • Contact: Echo Ouyang, BSc; Phone Number: 85227664844; Email: echo.y.ouyang@polyu.edu.hk
    • Contact: Marco YC Pang, PhD; Phone Number: 85227667156; Email: Marco.Pang@polyu.edu.hk

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 50 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• diagnosis of a stroke
• more than 6 months of stroke onset
• aged 50 years or above
• community-dwelling
• medically stable
• score ≥21 on the Montreal Cognitive Assessment (MoCA)
• score ≤ 25 on the Mini Balance Evaluation Systems Test (Mini-BESTest)
• able to ambulate without physical assistance of another person as determined during the 10-meter walk test
• ability to follow 3-step commands

Exclusion Criteria:

• having neurological conditions other than stroke
• not community-dwelling prior to the stroke event
• significant receptive and expressive aphasia
• severe and uncorrected hearing or visual deficits
• serious musculoskeletal disorders (e.g. amputation)
• serious cardiovascular conditions affecting the ability to participate in exercise training
• pain experienced at rest or movement
• other serious illnesses that preclude participation

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

3

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Dual-task training group; Participants in this group will receive dual-task balance and gait training for half hour and relaxation exercise for another half hour in each session. There will be 3 sessions per week for 8 weeks.	Behavioral: Dual-task training group; Balance and gait exercises while simultaneously engaging in a secondary cognitive task.
Active Comparator: Single-task training group; This group of subjects will participate in single-task gait and balance activities for half hour and single-task cognitive training in sitting position for another half hour in each session. There will be 3 sessions per week for 8 weeks.	Behavioral: Single-task training group; Balance/gait exercises and cognitive exercises done separately.
Active Comparator: Flexibility and strength training group; The subjects in this group will engage in flexibility exercises and upper limb strengthening exercises for one hour in each session. There will be 3 sessions per week for 8 weeks.	Behavioral: Flexibility and strength training group; Whole-body flexibility exercises, upper limb strengthening exercises.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Timed-up-and-go test with and without dual-task	A walking test	week 0
Timed-up-and-go test with and without dual-task	A walking test	week 8
Timed-up-and-go test with and without dual-task	A walking test	week 16

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
10-meter walk test with and without dual-task	A walking test	week 0
10-meter walk test with and without dual-task	A walking test	week 8
10-meter walk test with and without dual-task	A walking test	week 16
Sensory organization test with and without dual-task	A standing balance test	week 0
Sensory organization test with and without dual-task	A standing balance test	week 8
Sensory organization test with and without dual-task	A standing balance test	week 16
Obstacle crossing with and without dual-task	A walking test	week 0
Obstacle crossing with and without dual-task	A walking test	week 8
Obstacle crossing with and without dual-task	A walking test	week 16
Mini-Balance Evaluations Systems Test	A balance test	week 0
Mini-Balance Evaluations Systems Test	A balance test	week 8
Mini-Balance Evaluations Systems Test	A balance test	week 16
Activities-specific balance confidence scale	A questionnaire	week 0
Activities-specific balance confidence scale	A questionnaire	week 8
Activities-specific balance confidence scale	A questionnaire	week 16
Stroke Specific Quality of Life Scale	A questionnaire	week 0
Stroke Specific Quality of Life Scale	A questionnaire	week 8
Stroke Specific Quality of Life Scale	A questionnaire	week 16
Motricity Index	A muscle strength test	week 0
Motricity Index	A muscle strength test	week 8
Motricity Index	A muscle strength test	week 16
Chedoke Arm and Hand Activity Inventory	An arm function test	week 0
Chedoke Arm and Hand Activity Inventory	An arm function test	week 8
Chedoke Arm and Hand Activity Inventory	An arm function test	week 16
Frenchay Activities Index	A questionnaire	week 0
Frenchay Activities Index	A questionnaire	week 8
Frenchay Activities Index	A questionnaire	week 16
Tinetti Assessment Tool (Gait)	A walking test	week 0
Tinetti Assessment Tool (Gait)	A walking test	week 8
Tinetti Assessment Tool (Gait)	A walking test	week 16
Incidence of fall	fall follow-up using log book and monthly telephone calls	week 0-6 months after training
Global Rating of Change score	A questionnaire	week 8
Global Rating of Change score	A questionnaire	week 16
Upper limb muscle strength	dynamometry test	week 0
Upper limb muscle strength	dynamometry test	week 8
Upper limb muscle strength	dynamometry test	week 16

Collaborators and Investigators

• Sponsor: The Hong Kong Polytechnic University
• Collaborators: West China Hospital

Publications and helpful links

General Publications

• Pichierri G, Wolf P, Murer K, de Bruin ED. Cognitive and cognitive-motor interventions affecting physical functioning: a systematic review. BMC Geriatr. 2011 Jun 8;11:29. doi: 10.1186/1471-2318-11-29.
• Said CM, Galea MP, Lythgo N. People with stroke who fail an obstacle crossing task have a higher incidence of falls and utilize different gait patterns compared with people who pass the task. Phys Ther. 2013 Mar;93(3):334-44. doi: 10.2522/ptj.20120200. Epub 2012 Oct 11.
• Cockburn J, Haggard P, Cock J, Fordham C. Changing patterns of cognitive-motor interference (CMI) over time during recovery from stroke. Clin Rehabil. 2003 Mar;17(2):167-73. doi: 10.1191/0269215503cr597oa.
• Silsupadol P, Lugade V, Shumway-Cook A, van Donkelaar P, Chou LS, Mayr U, Woollacott MH. Training-related changes in dual-task walking performance of elderly persons with balance impairment: a double-blind, randomized controlled trial. Gait Posture. 2009 Jun;29(4):634-9. doi: 10.1016/j.gaitpost.2009.01.006. Epub 2009 Feb 7.
• Yang YR, Wang RY, Chen YC, Kao MJ. Dual-task exercise improves walking ability in chronic stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007 Oct;88(10):1236-40. doi: 10.1016/j.apmr.2007.06.762.
• Pang MYC, Yang L, Ouyang H, Lam FMH, Huang M, Jehu DA. Dual-Task Exercise Reduces Cognitive-Motor Interference in Walking and Falls After Stroke. Stroke. 2018 Dec;49(12):2990-2998. doi: 10.1161/STROKEAHA.118.022157.

Study record dates

Study Major Dates

• Study Start: October 1, 2014
• Primary Completion (Anticipated): June 1, 2016
• Study Completion (Anticipated): December 1, 2016

Study Registration Dates

• First Submitted: October 17, 2014
• First Submitted That Met QC Criteria: October 17, 2014
• First Posted (Estimate): October 21, 2014

Study Record Updates

• Last Update Posted (Estimate): November 11, 2014
• Last Update Submitted That Met QC Criteria: November 9, 2014
• Last Verified: November 1, 2014

More Information

Terms related to this study

• Keywords: Rehabilitation; Exercise; Balance; Gait; Dual-task; Community
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Stroke
• Other Study ID Numbers: HSEARS20140714003-01