Dual-Task Abilities During Activities Representative of Daily Life in Community-Dwelling Stroke Survivors: A Pilot Study

Grocery shopping as an outcome measure: A scoping review

BACKGROUND

Grocery shopping is a complex Instrumental Activity of Daily Living (IADL) requiring cognitive and physical components that can be used to assess functional performance. Real-world physical and cognitive demands of grocery shopping occur simultaneously; however, many existing outcome measures only include a single domain or subtask. The objective of this review is to examine how grocery shopping as a whole, or multiple simultaneous subtasks of grocery shopping, has been used as a functional outcomes measure.

METHODS

Peer-reviewed manuscripts in the English language were retrieved from PubMed, Medline, Scopus, and Cochrane published on or before December 20, 2024. Articles were included if an outcome measure included multiple subtasks of grocery shopping and excluded if an outcome was related to only a single subtask of grocery shopping. Extracted data included Author(s), Publication Title, Publication Year, Study Location, Study population, Grocery Setting (Virtual, Real-World, Simulated, or Patient Reported Answers), Grocery-specific measure, and Grocery-Specific outcome results.

RESULTS

Fifty-eight studies were included from 15 different countries. The most common populations studied were healthy adults (15) and psychiatric disorders (15). Common methods of assessment included patient-reported outcome measures (22), virtual reality (17), and physically simulated or real grocery shopping (20). Only three studies examined naturalistic, free-living grocery shopping. Outcomes were related to cognitive functioning (28), physical or motor impairments (23), or behavioral aspects of shopping (9).

CONCLUSIONS

This review provides critical insights into how grocery shopping has been adopted as a performance outcome measure across populations and testing environments. Despite the growing recognition of grocery shopping as a useful measure, gaps remain in the literature, especially related to a lack of studies that integrate cognitive and physical domains or explore its use in populations with combined cognitive and physical impairments.

Cognitive-motor dual-task training on gait and balance in stroke patients: meta-analytic report and trial sequential analysis of randomized clinical trials

OBJECTIVE

Cognitive-motor dual-tasking training (CMDT) might improve limb function and motor performance in stroke patients. However, is there enough evidence to prove that it is more effective compared with conventional physical single-task training? This meta-analysis and Trial Sequential Analysis of randomized clinical trials (RCTs) aimed to evaluate the effectiveness of CMDT on balance and gait for treating hemiplegic stroke patients.

METHODS

The databases were searched in PubMed, Web of Science, Ovid Database and The Cochrane Library, SinoMed database, Chinese National Knowledge Infrastructure (CNKI), Wan Fang database, and VIP database up to December 8, 2023. The Cochrane-recommended risk of bias (RoB) 2.0 tool was employed to assess risk of bias in trials. The statistical analysis was employed using R version 4.3.2. In addition, subgroup analyses and meta-regression were performed to explore the possible sources of heterogeneity. The evidence for each outcome was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. The Copenhagen Trial Unit's Trial Sequential Analysis (version 0.9.5.10 Beta) was used for sequential analysis.

RESULTS

Seventeen randomized clinical trials (RCTs) (n = 751 patients) were included. The results demonstrated that cognitive-motor dual-task training (CMDT) might be beneficial on stroke patients on Berg Balance Scale (BBS) (MD = 4.26, 95% CI 1.82, 6.69, p < 0.0001) (low-quality evidence). However, CMDT might not affect Time Up and Go test (TUG) (MD = -1.28, 95% CI -3.63, 1.06, p = 0.284); and single-task walking speed (MD = 1.35, 95% CI -1.56, 4.27, p = 0.413) in stroke patients (low-quality evidence). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) results indicated that all findings were very low to low certainty. Trial Sequential Analyses demonstrated larger sample sizes are required for confirming our findings.

CONCLUSION

Cognitive-motor dual-task training (CMDT) compared with conventional physical single-task training might be an effective intervention for improving static balance function in stroke patients (low-quality evidence), which should be interpreted cautiously due to heterogeneity and potential biases. Nevertheless, further research is required to support the abovementioned findings. Trial Registration This protocol was registered in PROSPERO (CRD42023490530).

Towards a comprehensive framework for complex walking tasks: Characterization, behavioral adaptations, and clinical implications in ageing and neurological populations

Complex walking tasks, including change of direction, patterns and rhythms, require more attentional resources than simple walking and significantly impact walking performance, especially among ageing and neurological populations. More studies have been focusing on complex walking situations, with or without the addition of cognitive tasks, creating a multitude of walking situations. Given the lack of a clear and extensive definition of complex walking, this narrative review aims to identify and more precisely characterize situations and related tests, improve understanding of behavioral adaptations in ageing and neurological populations, and report the clinical applications of complex walking. Based on the studies collected, we are proposing a framework that categorizes the different forms of complex walking, considering whether a cognitive task is added or not, as well as the number of distinct objectives within a given situation. We observed that combining complex walking tasks with a cognitive assignment places even greater strain on attentional resources, resulting in a more pronounced decline in walking and/or cognitive performance. This work highlights the relevance of complex walking as a simple tool for early detection of cognitive impairments and risk of falls, and its potential value in cognitive-motor rehabilitation. Future studies should explore various complex walking tasks in ageing and neurological populations, under varied conditions in real-life or in extended virtual environments.

Development of a virtual reality-based intervention for community walking post stroke: an integrated knowledge translation approach

PURPOSE

To develop a virtual reality (VR) based intervention targeting community walking requirements.

METHODS

Two focus groups each involving 7 clinicians allowed exploring optimal features, needed support and perceived favorable/unfavorable factors associated with the use of the VR-based intervention from the clinicians' perspective. Three stroke survivors and 2 clinicians further interacted with the intervention and filled questionnaires related to acceptability and favorable/unfavorable perceptions on the VR intervention. Stroke participants additionally rated their perceived effort (NASA Tax Load Index), presence (Slater-Usoh-Steed) and cybersickness (Simulator Sickness Questionnaire).

RESULTS

Results identified optimal features (patient eligibility criteria, task complexity), needed support (training, human assistance), as well as favorable (cognitive stimulation, engagement, representativeness of therapeutic goals) and unfavorable factors (misalignment with a natural walking pattern, client suitability, generalization to real-life) associated with the intervention. Acceptability scores following the interaction with the tool were 28 and 42 (max 56) for clinicians and ranged from 43 to 52 for stroke participants. Stroke participants reported moderate perceptions of effort (range:20-33/max:60), high levels of presence (29-42/42) and minimal cybersickness (0-3/64).

CONCLUSION

Findings collected in the early development phase of the VR intervention will allow addressing favorable/unfavorable factors and incorporating desired optimal features, prior to conducting effectiveness and implementation studies.

Dual-Task Performance and Brain Morphologic Characteristics in Parkinson's Disease

INTRODUCTION

Parkinson's disease (PD) reduces an individual's capacity for automaticity which limits their ability to perform two tasks simultaneously, negatively impacting daily function. Understanding the neural correlates of dual tasks (DTs) may pave the way for targeted therapies. To better understand automaticity in PD, we aimed to explore whether individuals with differing DT performances possessed differences in brain morphologic characteristics.

METHODS

Data were obtained from 34 individuals with PD and 47 healthy older adults including (1) demographics (age, sex), (2) disease severity (Movement Disorder Society - Unified Parkinson's Disease Rating Scale [MDS-UPDRS], Hoehn and Yahr, levodopa equivalent daily dose [LEDD]), (3) cognition (Montreal Cognitive Assessment), (4) LEDD, (5) single-task and DT performance during a DT-timed-up-and-go test utilizing a serial subtraction task, and (6) cortical thicknesses and subcortical volumes obtained from volumetric MRI. Participants were categorized as low or high DT performers if their combined DT effect was greater than the previously determined mean value for healthy older adults (μ = -74.2). Nonparametric testing using Quade's ANCOVA was conducted to compare cortical thicknesses and brain volumes between the highDT and lowDT groups while controlling for covariates: age, sex, MDS-UPDRS part III, LEDD, and intracranial volume. Secondarily, similar comparisons were made between the healthy older adult group and the highDT and lowDT groups. Lastly, a hierarchical linear regression model was conducted regressing combined DT effect on covariates (block one) and cortical thicknesses (block 2) in stepwise fashion.

RESULTS

The highDT group had thicker cortices than the lowDT group in the right primary somatosensory cortex (p = 0.001), bilateral primary motor cortices (p ≤ 0.001, left; p = 0.002, right), bilateral supplementary motor areas (p = 0.001, left; p < 0.001, right), and mean of the bilateral hemispheres (p = 0.001, left; p < 0.001, right). Of note, left primary cortex thickness (p = 0.002), left prefrontal cortex thickness (p < 0.001), and right supplementary motor area thickness (p = 0.003) differed when adding a healthy comparison group. Additionally, the regression analysis found that the left paracentral lobule thickness explained 20.8% of the variability in combined DT effect (p = 0.011) beyond the influence of covariates.

CONCLUSIONS

These results suggest regions underlying DT performance, specifically, a convergence of neural control relying on sensorimotor integration, motor planning, and motor activation to achieve higher levels of DT performance for individuals with PD.

INTRODUCTION

Parkinson's disease (PD) reduces an individual's capacity for automaticity which limits their ability to perform two tasks simultaneously, negatively impacting daily function. Understanding the neural correlates of dual tasks (DTs) may pave the way for targeted therapies. To better understand automaticity in PD, we aimed to explore whether individuals with differing DT performances possessed differences in brain morphologic characteristics.

METHODS

Data were obtained from 34 individuals with PD and 47 healthy older adults including (1) demographics (age, sex), (2) disease severity (Movement Disorder Society - Unified Parkinson's Disease Rating Scale [MDS-UPDRS], Hoehn and Yahr, levodopa equivalent daily dose [LEDD]), (3) cognition (Montreal Cognitive Assessment), (4) LEDD, (5) single-task and DT performance during a DT-timed-up-and-go test utilizing a serial subtraction task, and (6) cortical thicknesses and subcortical volumes obtained from volumetric MRI. Participants were categorized as low or high DT performers if their combined DT effect was greater than the previously determined mean value for healthy older adults (μ = -74.2). Nonparametric testing using Quade's ANCOVA was conducted to compare cortical thicknesses and brain volumes between the highDT and lowDT groups while controlling for covariates: age, sex, MDS-UPDRS part III, LEDD, and intracranial volume. Secondarily, similar comparisons were made between the healthy older adult group and the highDT and lowDT groups. Lastly, a hierarchical linear regression model was conducted regressing combined DT effect on covariates (block one) and cortical thicknesses (block 2) in stepwise fashion.

RESULTS

The highDT group had thicker cortices than the lowDT group in the right primary somatosensory cortex (p = 0.001), bilateral primary motor cortices (p ≤ 0.001, left; p = 0.002, right), bilateral supplementary motor areas (p = 0.001, left; p < 0.001, right), and mean of the bilateral hemispheres (p = 0.001, left; p < 0.001, right). Of note, left primary cortex thickness (p = 0.002), left prefrontal cortex thickness (p < 0.001), and right supplementary motor area thickness (p = 0.003) differed when adding a healthy comparison group. Additionally, the regression analysis found that the left paracentral lobule thickness explained 20.8% of the variability in combined DT effect (p = 0.011) beyond the influence of covariates.

CONCLUSIONS

These results suggest regions underlying DT performance, specifically, a convergence of neural control relying on sensorimotor integration, motor planning, and motor activation to achieve higher levels of DT performance for individuals with PD.

Exploring the challenges of avoiding collisions with virtual pedestrians using a dual-task paradigm in individuals with chronic moderate to severe traumatic brain injury

BACKGROUND

Individuals with a moderate-to-severe traumatic brain injury (m/sTBI), despite experiencing good locomotor recovery six months post-injury, face challenges in adapting their locomotion to the environment. They also present with altered cognitive functions, which may impact dual-task walking abilities. Whether they present collision avoidance strategies with moving pedestrians that are altered under dual-task conditions, however, remains unclear. This study aimed to compare between individuals with m/sTBI and age-matched control individuals: (1), the locomotor and cognitive costs associated with the concurrent performance of circumventing approaching virtual pedestrians (VRPs) while attending to an auditory-based cognitive task and; (2) gaze behaviour associated with the VRP circumvention task in single and dual-task conditions.

METHODOLOGY

Twelve individuals with m/sTBI (age = 43.3 ± 9.5 yrs; >6 mo. post injury) and 12 healthy controls (CTLs) (age = 41.8 ± 8.3 yrs) were assessed while walking in a virtual subway station viewed in a head-mounted display. They performed a collision avoidance task with VRPs, as well as auditory-based cognitive tasks (pitch discrimination and auditory Stroop), both under single and dual-task conditions. Dual-task cost (DTC) for onset distance of trajectory deviation, minimum distance from the VRP, maximum lateral deviation, walking speed, gaze fixations and cognitive task accuracy were contrasted between groups using generalized estimating equations.

RESULTS

In contrast to CTLs who showed locomotor DTCs only, individuals with m/sTBI displayed both locomotor and cognitive DTCs. While both groups walked slower under dual-task conditions, only individuals with m/sTBI failed to modify their onset distance of trajectory deviation and maintained smaller minimum distances and smaller maximum lateral deviation compared to single-task walking. Both groups showed shorter gaze fixations on the approaching VRP under dual-task conditions, but this reduction was less pronounced in the individuals with m/sTBI. A reduction in cognitive task accuracy under dual-task conditions was found in the m/sTBI group only.

CONCLUSION

Individuals with m/sTBI present altered locomotor and gaze behaviours, as well as altered cognitive performances, when executing a collision avoidance task involving moving pedestrians in dual-task conditions. Potential mechanisms explaining those alterations are discussed. Present findings highlight the compromised complex walking abilities in individuals with m/sTBI who otherwise present a good locomotor recovery.

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.

Single and Dual Task Gait Speed in Frailty Screening of Community-Dwelling Older Adults

OBJECTIVE

This study compares dual task (DT) gait speed between robust and frail older adults in the setting of a community-based frailty screening program.

METHODS

A cross-sectional study was conducted involving older adults aged 50 years or older. Participants were categorized as robust, pre-frail or frail using the FRAIL phenotype. Gait speed was measured under single task (ST) and 2 DT conditions: arithmetic (DT1) and verbal fluency (DT2) tasks. For the arithmetic task, participants counted upwards in multiples of 2, starting from 16. For the verbal fluency task, they named different animals as they walked.

RESULTS

A total of 976 participants were recruited, of which 779 were robust, 181 were pre-frail and 16 were frail. Robust participants exhibited significantly faster DT gait speeds (DT1: 1.12 (0.25)m/s; DT2: 0.97 (0.27)m/s than pre-frail/frail (PFF) participants (DT1: 0.88 (0.30)m/s); DT2: 0.78 (0.30)m/s). Robust participants also demonstrated a significantly faster ST gait speed (1.31 (0.22)m/s) vs 1.05 (0.31)m/s).

CONCLUSION

DT gait assessment combines both physical and cognitive domains and may serve as a more holistic tool for early frailty detection in the community. The significant differences observed in DT gait speeds highlight the need for integrating cognitive assessments into frailty screening protocols, supporting timely interventions to improve health outcomes.

VR for Vocational and Ecological Rehabilitation of Patients With Cognitive Impairment: A Survey

Cognitive impairment arises from various brain injuries or diseases, such as traumatic brain injury, stroke, schizophrenia, or cancer-related cognitive impairment. Cognitive impairment can be an obstacle for patients to the return-to-work. Research suggests various interventions using technology for cognitive and vocational rehabilitation. The present work offers an overview of sixteen vocational or ecological VR-based clinical studies among patients with cognitive impairment. The objective is to analyze these studies from a VR perspective focusing on the VR apparatus and tasks, adaptivity, transferability, and immersion of the interventions. Our results highlight how a higher level of immersion could bring the participants to a deeper level of engagement and transferability, rarely assessed in current literature, and a lack of adaptivity in studies involving patients with cognitive impairments. From these considerations, we discuss the challenges of creating a standardized yet adaptive protocol and the perspectives of using immersive technologies to allow precise monitoring, personalized rehabilitation and increased commitment.

Immersive Virtual Reality during Robot-Assisted Gait Training: Validation of a New Device in Stroke Rehabilitation

Background and objective: Duration of rehabilitation and active participation are crucial for gait rehabilitation in the early stage after stroke onset. Virtual reality (VR) is an innovative tool providing engaging and playful environments that could promote intrinsic motivation and higher active participation for non-ambulatory stroke patients when combined with robot-assisted gait training (RAGT). We have developed a new, fully immersive VR application for RAGT, which can be used with a head-mounted display and wearable sensors providing real-time gait motion in the virtual environment. The aim of this study was to validate the use of this new device and assess the onset of cybersickness in healthy participants before testing the device in stroke patients. Materials and Methods: Thirty-seven healthy participants were included and performed two sessions of RAGT using a fully immersive VR device. They physically walked with the Gait Trainer for 20 min in a virtual forest environment. The occurrence of cybersickness, sense of presence, and usability of the device were assessed with three questionnaires: the Simulator Sickness Questionnaire (SSQ), the Presence Questionnaire (PQ), and the System Usability Scale (SUS). Results: All of the participants completed both sessions. Most of the participants (78.4%) had no significant adverse effects (SSQ < 5). The sense of presence in the virtual environment was particularly high (106.42 ± 9.46). Participants reported good usability of the device (86.08 ± 7.54). Conclusions: This study demonstrated the usability of our fully immersive VR device for gait rehabilitation and did not lead to cybersickness. Future studies should evaluate the same parameters and the effectiveness of this device with non-ambulatory stroke patients.