Dual-task walking and automaticity after Stroke: Insights from a secondary analysis and imaging sub-study of a randomised controlled trial.

OBJECTIVE: To test the extent to which initial walking speed influences dual-task performance after walking intervention, hypothesising that slow walking speed affects automatic gait control, limiting executive resource availability. DESIGN: A secondary analysis of a trial of dual-task (DT) and single-task (ST) walking interventions comparing those with good (walking speed ⩾0.8 m s-1, n = 21) and limited (walking speed <0.79 m s-1, n = 24) capacity at baseline. SETTING: Community. SUBJECTS: Adults six-months post stroke with walking impairment. INTERVENTIONS: Twenty sessions of 30 minutes treadmill walking over 10 weeks with (DT) or without (ST) cognitive distraction. Good and limited groups were formed regardless of intervention received. MAIN MEASURES: A two-minute walk with (DT) and without (ST) a cognitive distraction assessed walking. fNIRS measured prefrontal cortex activation during treadmill walking with (DT) and without (ST) Stroop and planning tasks and an fMRI sub-study used ankle-dorsiflexion to simulate walking. RESULTS: ST walking improved in both groups (∆baseline: Good = 8.9 ± 13.4 m, limited = 5.3±8.9 m, Group × time = P < 0.151) but only the good walkers improved DT walking (∆baseline: Good = 10.4 ± 13.9 m, limited = 1.3 ± 7.7 m, Group × time = P < 0.025). fNIRS indicated increased ispilesional prefrontal cortex activation during DT walking following intervention (P = 0.021). fMRI revealed greater DT cost activation for limited walkers, and increased resting state connectivity of contralesional M1 with cortical areas associated with conscious gait control at baseline. After the intervention, resting state connectivity between ipsilesional M1 and bilateral superior parietal lobe, involved in integrating sensory and motor signals, increased in the good walkers compared with limited walkers. CONCLUSION: In individual who walk slowly it may be difficult to improve dual-task walking ability.Registration: ISRCTN50586966.

Prefrontal Cortex Activation While Walking Under Dual-Task Conditions in Stroke: A Multimodal Imaging Study.

Background Walking while performing another task (eg, talking) is challenging for many stroke survivors, yet its neural basis are not fully understood. Objective To investigate prefrontal cortex activation and its relationship to gait measures while walking under single-task (ST) and dual-task (DT) conditions (ie, walking while simultaneously performing a cognitive task) in stroke survivors. Methods We acquired near-infrared spectroscopy (NIRS) data from the prefrontal cortex during treadmill walking in ST and DT conditions in chronic stroke survivors and healthy controls. We also acquired functional magnetic resonance imaging (fMRI) and NIRS during simulated walking under these conditions. Results NIRS revealed increased oxygenated hemoglobin concentration in DT-walking compared with ST-walking for both groups. For simulated walking, NIRS showed a significant effect of group and group × task, being greater on both occasions, in stroke survivors. A greater increase in brain activation observed from ST to DT walking/ simulated walking was related to a greater change in motor performance in stroke survivors. fMRI revealed increased activity during DT relative to ST conditions in stroke patients in areas including the inferior temporal gyri, superior frontal gyri and cingulate gyri bilaterally, and the right precentral gyrus. The DT-related increase in fMRI activity correlated with DT-related change in behavior in stroke participants in the bilateral inferior temporal gyrus, left cingulate gyrus, and left frontal pole. Conclusion Our results provide novel evidence that enhanced brain activity changes relate to dual task motor decrements.

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence.

BACKGROUND: Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments. OBJECTIVE: To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base. METHODS: Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012. RESULTS: Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified. CONCLUSIONS: There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

Prospective memory and ageing paradox with event-based tasks: a study of young, young-old, and old-old participants.

Research on ageing and prospective memory--remembering to do something in the future--has resulted in paradoxical findings, whereby older adults are often impaired in the laboratory but perform significantly better than younger adults in naturalistic settings. Nevertheless, there are very few studies that have examined prospective memory both in and outside the laboratory using the same sample of young and old participants. Moreover, most naturalistic studies have used time-based tasks, and it is unclear whether the prospective memory and ageing paradox extends to event-based tasks. In this study, 72 young (18-30 years), 79 young-old (61-70 years), and 72 old-old (71-80 years) participants completed several event-based tasks in and outside the laboratory. Results showed that the ageing paradox does exist for event-based tasks but manifests itself differently from that in time-based tasks. Thus, younger adults outperformed old-old participants in two laboratory event-based tasks, but there were no age effects for a naturalistic task completed at home (remembering to write the date and time in the upper left corner of a questionnaire). The young and old-old also did not differ in remembering to retrieve a wristwatch from a pocket at the end of the laboratory session. This indicates that the paradox may be due to differences in ongoing task demands in the lab and everyday life, rather than the location per se. The findings call for a concentrated effort towards a theory of cognitive ageing that identifies the variables that do, or do not, account for this paradox.

Cognitive context determines dorsal premotor cortical activity during hand movement in patients after stroke.

BACKGROUND AND PURPOSE: Stroke patients often have difficulties in simultaneously performing a motor and cognitive task. Functional imaging studies have shown that movement of an affected hand after stroke is associated with increased activity in multiple cortical areas, particularly in the contralesional hemisphere. We hypothesized patients for whom executing simple movements demands greater selective attention will show greater brain activity during movement. METHODS: Eight chronic stroke patients performed a behavioral interference test using a visuo-motor tracking with and without a simultaneous cognitive task. The magnitude of behavioral task decrement under cognitive motor interference (CMI) conditions was calculated for each subject. Functional MRI was used to assess brain activity in the same patients during performance of a visuo-motor tracking task alone; correlations between CMI score and movement-related brain activation were then explored. RESULTS: Movement-related activation in the dorsal precentral gyrus of the contralesional hemisphere correlated strongly and positively with CMI score (r(2) at peak voxel=0.92; P<0.05). Similar but weaker relationships were observed in the ventral precentral and middle frontal gyrus. There was no independent relationship between hand motor impairment and CMI. CONCLUSIONS: Results suggest that variations in the degree to which a cognitive task interferes with performance of a concurrent motor task explains a substantial proportion of the variations in movement-related brain activity in patients after stroke. The results emphasize the importance of considering cognitive context when interpreting brain activity patterns and provide a rationale for further evaluation of integrated cognitive and movement interventions for rehabilitation in stroke.

Cognitive motor interference while walking: a systematic review and meta-analysis.

Dual-task methodology has been increasingly used to assess cognitive motor interference while walking. However, whether the observed dual-task-related gait changes are systematically related to methodological variations remains unclear and researchers still lack knowledge of what cognitive task to use in different groups for clinical purposes or for research. We systematically reviewed experimental studies that measured gait performance with and without performing concurrent cognitive task. Our results suggest that cognitive tasks that involve internal interfering factors seem to disturb gait performance more than those involving external interfering factors. Meta-analysis results show that the overall effect of different cognitive tasks was prominent in gait speed. In healthy participants, meta-regression analysis suggests strong associations between age and speed reduction under dual-task conditions and between the level of cognitive state and speed reduction under dual-task conditions. Standardizing research methodologies, as well as improving their ecological validity, enables better understanding of dual-task-related gait changes in different populations and improves, in turn, our understanding of neural mechanisms and gait control in general in content.

Gait adaptations to simultaneous cognitive and mechanical constraints.

Previous studies have shown that walking is not a purely automatic motor task but places demands on sensory and cognitive systems. We set out to investigate whether complex walking tasks, as when walking down a steeper gradient while performing a concurrent cognitive task, would demand gait adaptation beyond those required for walking under low-challenge conditions. Thirteen healthy young individuals walked at their self-selected speed on a treadmill at different inclinations (0, -5 and -10%). Gait spatio-temporal measures, pelvis angular excursion, and sacral centre of mass (CoM) motion were acquired while walking or while walking and performing a mental tracking task. Repeated-measures ANOVAs revealed that decreasing treadmill inclination from 0 to -10% resulted in significant decreased walking speed (P < 0.001), decreased stride length (P < 0.001), increased pelvis tilt (P = 0.006) and obliquity variability (P = 0.05), decreased pelvis rotation (P = 0.02), and increased anterio-posterior (A-P) CoM displacement (P = 0.015). Compared to walking alone, walking under dual-task condition resulted in increased step width (P < 0.001), and increased medio-lateral (M-L) CoM displacement (P = 0.039) regardless of inclination grade, while sagittal plane dynamics did not change. Findings suggest that gait adapts differently to cognitive and mechanical constraints; the cognitive system is more actively involved in controlling frontal than sagittal plane gait dynamics, while the reverse is true for the mechanical system. Finally, these findings suggest that gait adaptations maintain the ability to perform concurrent tasks while treadmill walking in healthy young adults.

Fast walking under cognitive-motor interference conditions in chronic stroke.

Gait in stroke patients is often characterised by slower speeds, which may be exacerbated by situations that combine gait with a cognitive task, leading to difficulties with everyday activities. Interaction between cognitive task performance and gait speed may differ according to walking intensity. This study examines the effects of two cognitive tasks on gait at preferred walking pace, and at a faster pace, using dual-task methodology. 21 chronic stroke patients and 10 age-matched control subjects performed 2 single motor tasks (walking at preferred and at fast pace around a walkway), and two cognitive tasks (serial subtractions of 3s and a visual-spatial decision task) under single- and dual-task conditions (cognitive-motor interference) in a randomised order. Cognitive task score and gait speed were measured. The healthy control group showed no effects of CMI. The stroke group decreased their walking speed whilst concurrently performing serial 3s during both preferred and fast walking trials and made more mistakes in the visuo-spatial task during fast walking. There was no effect of walking on the serial 3 performance. The findings show that in stroke patients, during walking whilst concurrently counting backwards in 3s the cognitive task appeared to take priority over maintenance of walking speed. During fast walking whilst concurrently performing a visuo-spatial imagery task, they appeared to favour walking. This may indicate that people spontaneously favour one activity over the other, which has implications for gait rehabilitation.

Differential effects of age on prospective and retrospective memory tasks in young, young-old, and old-old adults.

Remembering to do something in the future (termed prospective memory) is distinguished from remembering information from the past (retrospective memory). Because prospective memory requires strong self-initiation, Craik (1986) predicted that age decrements should be larger in prospective than retrospective memory tasks. The aim of the present study was to assess Craik's prediction by examining the onset of age decline in two retrospective and three prospective memory tasks in the samples of young (18-30 years), young-old (61-70 years), and old-old (71-80 years) participants recruited from the local community. Results showed that although the magnitude of age effects varied across the laboratory prospective memory tasks, they were smaller than age effects in a simple three-item free recall task. Moreover, while reliable age decrements in both retrospective memory tasks of recognition and free recall were already present in the young-old group, in laboratory tasks of prospective memory they were mostly present in the old-old group only. In addition, older participants were more likely to report a retrospective than prospective memory failure as their most recent memory lapse, while the opposite pattern was present in young participants. Taken together, these findings highlight the theoretical importance of distinguishing effects of ageing on prospective and retrospective memory, and support and extend the results of a recent meta-analysis by Henry, MacLeod, Phillips, and Crawford (2004).

Borg's rating of perceived exertion scales: do the verbal anchors mean the same for different clinical groups?

OBJECTIVE: To examine the interpretation of the verbal anchors used in the Borg rating of perceived exertion (RPE) scales in different clinical groups and a healthy control group. DESIGN: Prospective experimental study. SETTING: Rehabilitation center. PARTICIPANTS: Nineteen subjects with brain injury, 16 with chronic low back pain (CLBP), and 20 healthy controls. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects used a visual analog scale (VAS) to rate their interpretation of the verbal anchors from the Borg RPE 6-20 and the newer 10-point category ratio scale. RESULTS: All groups placed the verbal anchors in the order that they occur on the scales. There were significant within-group differences ( P >.05) between VAS scores for 4 verbal anchors in the control group, 8 in the CLBP group, and 2 in the brain injury group. There was no significant difference in rating of each verbal anchor between the groups ( P >.05). CONCLUSIONS: All subjects rated the verbal anchors in the order they occur on the scales, but there was less agreement in rating of each verbal anchor among subjects in the brain injury group. Clinicians should consider the possibility of small discrepancies in the meaning of the verbal anchors to subjects, particularly those recovering from brain injury, when they evaluate exercise perceptions.

The effect of a perceptual cognitive task on exercise performance: the dual-task condition after brain injury.

OBJECTIVE: To examine the effect of additional cognitive demand on cycling performance in individuals with acquired brain injury (ABI). DESIGN: Prospective observational study. SETTING: Rivermead Rehabilitation Centre. PARTICIPANTS: Ten individuals with ABI (7 men, 3 women) (traumatic brain injury 7, tumour 1, stroke 2) and 10 healthy controls (6 men, 4 women). INTERVENTION: Individuals were asked to maintain a set cadence during a three-stage incremental cycling test in both single-task (no additional task) and dual-task (whilst performing an additional cognitive task) conditions. RESULTS: The ABI group showed a slight slowing in cadence in stages 1 and 3 of the graded exercise test from the single- to the dual-task condition, although this was not significant (p < or = 0.05). The control group showed no slowing of cadence at any incremental stage. When directly comparing the ABI with the control group, the change in cadence observed in dual-task conditions was only significantly different in stage 3 (p < or = 0.05). CONCLUSIONS: Clinicians should be aware of the possibility that giving additional cognitive tasks (such as monitoring exercise intensity) while individuals with acquired brain injury are performing exercises may detrimentally affect performance. The effect may be more marked when the individuals are performing exercise at higher intensities.

Who knows best? Awareness of divided attention difficulty in a neurological rehabilitation setting.

OBJECTIVE: To explore whether patients relearning to walk after acquired brain injury and showing cognitive-motor interference were aware of divided attention difficulty; whether their perceptions concurred with those of treating staff. DESIGN: Patients and neurophysiotherapists (from rehabilitation and disabled wards) completed questionnaires. Factor analyses were applied to responses. Correlations between responses, clinical measures and experimental decrements were examined. RESULTS: Patient/staff responses showed some agreement; staff reported higher levels of perceived difficulty; responses conformed to two factors. One factor (staff/patients alike) reflected expectations about functional/motor status and did not correlate with decrements. The other factor (patients) correlated significantly with dual-task motor decrement, suggesting some genuine awareness of difficulty (cognitive performance prioritized over motor control). The other factor (staff) correlated significantly with cognitive decrement (gait prioritized over sustained attention). CONCLUSIONS: Despite some inaccurate estimation of susceptibility; patients and staff do exhibit awareness of divided attention difficulty, but with a limited degree of concurrence. In fact, our results suggest that patients and staff may be sensitive to different aspects of the deficit. Rather than 'Who knows best?', it is a question of 'Who knows what?'

Changing patterns of cognitive-motor interference (CMI) over time during recovery from stroke.

OBJECTIVE: To explore the extent and nature of change in cognitive-motor interference (CMI) among rehabilitating stroke patients who showed dual-task gait decrement at initial assessment. DESIGN: Experimental, within-subjects, repeated measures design. SETTING: Rehabilitation centre for adults with acquired, nonprogressive brain injury. SUBJECTS: Ten patients with unilateral stroke, available for reassessment 1-9 months following their participation in a study of CMI after brain injury. MEASURES: Median stride duration; mean word generation. METHODS: Two x one-minute walking trials, two x one-minute word generation trials, two x one-minute trials of simultaneous walking and word generation; 10-metre walking time; Barthel ADL Scale score. RESULTS: Seven out of ten patients showed reduction over time in dual-task gait decrement. Three out of ten showed reduction in cognitive decrement. Only one showed concomitant reduction in gait and word generation decrement. CONCLUSION: Extent of CMI during relearning to walk after a stroke reduced over time in the majority of patients. Effects were more evident in improved stride duration than improved cognitive performance. Measures of multiple task performance should be included in assessment for functional recovery.