Introduction
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Which types of training programmes (specific versus general training, ST versus DT training) are most effective to improve DT performance? That is, which training effects on ST and DT motor performance while standing or walking were reported and which benefits for cognitive performance under ST and DT conditions were described with regard to different types of intervention?
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Do the training effects differ between different complex cognitive tasks/cognitive tasks with different characteristics and between different standing and walking tasks?
Methods
Database sources and search terms
Search stage | Papers retained | ||
---|---|---|---|
Medline | EMBASE | PsycINFO | |
1. age or old$ or "advanced age" or senior$ or elder$ or geriatric$ or aged or eldest or geronic or aging | 5,071,761 | 3,934,136 | 577,515 |
2. "corresponding task$" or "coupled task$" or "dual task$" or "dual task paradigm$" or "secondary task" or "conflicting task" or "task priori#ation" or "inattentional blindness" | 2,141 | 2,743 | 2,986 |
3. practice or train$ or improve$ or exercise or treatment or intervention | 3,542,216 | 4,936,819 | 793,454 |
4. motor or move$ or balance or posture or standing or walking | 643,441 | 726,053 | 179,721 |
5. Combination of 1 and 2 and 3 and 4 | 195 | 187 | 75 |
Assessment based on title and abstract | 55 | 42 | 29 |
Assessment based on reading the whole paper | 40 | 25 | 9 |
Total number of included papers | 13 |
Selection criteria
Randomized controlled trials (RCT) | ||||||
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Eligible study (first author) | Participants (n, sex, age (M, SD)) | Study aims | Intervention | Training duration (min) | Motor task and measurement | Cognitive task stimulus–response |
Hall [23] |
N = 15, n.a. | Effects of Tai Chi programme on balance | CG: n.a. | 2 × 90′ p.w. for 12 w. = 24 s = 2,160′ | Standing and walking, Sensori organisation test (SOT) and walking in an obstacle course | CP (A-Ve): two-choice reaction time test |
72.2 ± 7.7 | EG: GST | |||||
Hiyamazu [29] |
N = 43 | Investigate the effects of dual task balance training on standing postural control while performing a cognitive task | CG: GST | 2 × 60′ p.w. for 12 w. = 24 s 1,440′ | Chair stand test; functional reach; Timed up and go COP displacements | Trail making test A + B in single condition EC: (Vi-Ve) Stroop test |
CG: n = 19 | EG:GDT | |||||
16f/3 m; 71.2 ± 4.4 | ||||||
EG: n = 17 | ||||||
10f/7 m; 72 ± 5.1 | ||||||
Silsupadol [66] |
N = 21, n.a., ≥65 | Comparison of three different balance trainings (GST and GDT with fixed and variable task priority) on balance | EG1: GST | 3 × 45′ p.w. for 4 w. = 12 h = 540′ | Walking COP displacements, gait parameters (speed, stride length) narrow walk | EC (A-Ve): auditory Stroop task |
EG1: n = 7 | EG2 + 3: GDT | CP (A-Ve): counting backwards | ||||
EG2: n = 8 | ||||||
EG3: n = 6 | ||||||
Trombetti [80] |
N = 134 | Effects of a music-based exercise programme on gait, balance and fall risk | CG: -EG: GDT | 60′ p.w. for 12 m = 52 h = 3,120 | Walking variability (GAITRaite); angular velocity COP transducers | CP (A-Ve): counting backwards down from 50 |
CG: n = 68 (65 f/3 m) | ||||||
EG: n = 66 (64f/2 m) | ||||||
Westlake [93] |
N = 36, n.a. | Effects of sensori balance training on proprioceptive reintegration | CG: education EG:GDT | 3 × 60′ p.w. for 8 w. = 24 s = 1,440′ | Standing force platform, COP displacements after vibration disturbance | CP (A-Ve): counting backwards 3 s |
CG: n = 19, >65 | ||||||
EG: n = 17, >65 | ||||||
Dault [16] |
N = 30, n.a. | Training effects visual spatial dual task on postural sway while standing | SDT | 3 × 3 trials of 60″ = 9′ | Standing, force platform, COP displacements (RMS and mean power frequency) | VS (Vi-Ve): Manekin test |
YA: n = 15, 22 ± 1.5 | ||||||
OA: n = 15, 79.1 ± 4.9 | ||||||
Doumas [18] |
N = 18, f/m | Training effects on concurrent posture and working memory tasks | SDT | 11 × 30′ =330′ | Standing postural stability on tilting platform; COP displacements | EC (Vi-Ve): n-back task |
YA: n = 8, 26.6 ± 1.9 | ||||||
OA: n = 10, 66.9 ± 3.3 | ||||||
Bisson [9] |
n = 24; f/m | Comparison of Biofeedback and Virtual Reality Training on balance | BF: GST | 2 × 30′ p.w. for 10 w. = 20 s; 600′ | CB&M scale Standing on force platform; COP displacements (RMS) | PS (A-Ve): reaction on auditory cue |
BF: 74.4 ± 4.92 | VR: GDT | |||||
VR: 74.4 ± 3.65 | ||||||
Heiden and Lajoie [28] |
N = 16 | Games-based biofeedback training and the attentional demands of balance performance | CG: - | 2 × 30′ p.w. for 8 w. = 16 s = 480′ | CB&M scale | PS (A-Ve): reaction on auditory cue |
mean age 77 | EG: GDT | 6 min walk | ||||
CG: n = 7 (6f /1 m) | COP displacements (RMS) | |||||
EG: n = 9 (5f/4 m) | ||||||
Heiden and Lajoie [28] |
N = 16 | Games-based biofeedback training and the attentional demands of balance performance | CG: - | 2 × 30′ p.w. for 8 w. = 16 s = 480′ | CB&M scale | PS (A-Ve): reaction on auditory cue |
mean age 77 | EG: GDT | 6 min walk | ||||
CG: n = 7 (6f /1 m) | COP displacements (RMS) | |||||
EG: n = 9 (5f/4 m) | ||||||
Toulotte [79] |
N = 16, f | Comparison of effects of static and dynamic balance training for fallers and non-fallers | GDT | 2 × 60′ p.w. for 3 m = 24 h = 1,440′ | Walking and Standing under ST or DT, OLB, steps per min, speed, stride time, step time, single-support time, stride length; step length (additional motor task under DT) | n.a. |
F: n = 8, 71.1 ± 5 | ||||||
NF: n = 8, 68.4 ± 4.5 | ||||||
You [104] |
N = 13, n.a | Practice effects of a cognitive gait intervention on cognition and gait in Fallers | CG: SST | 18 × 30′ in 6 w. = 18 s = 540′ | Walking, gait velocity and stability (sway deviation (cm) of COP) | EC (A-M): word lists and calculating tasks over headphones; writing down remembered items |
CG: 68.0 ± 3.3 | ||||||
EG: 70.5 ± 6.8 | EG: SDT |
Study | Quality criteria | Quality score | General remarks | |||||||||||
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a | b | c | d | e | f | g | h | i | j | k | l | |||
RCTs | ||||||||||||||
Hall b [23] | x | – | – | – | u | u | u | u | – | x | x | (x) | 1 + 2 | k: statistical information missing, e.g., ES |
Hiyamazu [29] | x | x | x | x | u | u | x | u | – | x | x | x | 5 + 3 | |
Silsudapol [66] | x | x | x | x | x | x | x | x | x | x | x | (x) | 9 + 2 | Small SS |
Silsudapol [67] | x | x | x | x | x | x | x | x | x | x | x | (x) | 9 + 2 | Small SS |
Trombetti [80] | (x) | u | x | x | u | u | x | x | x | x | x | x | 5 + 3 | Randomization process unclear |
Westlake [93] | x | x | – | u | x | x | x | x | – | x | x | (x) | 6 + 2 | |
Age comparison designs
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Dault [16] | x | x | x | x | – | x | x | (x) | 4 + 2 | 6 trails only – f+g implicit | ||||
Doumas [18] | x | u | x | x | – | x | x | x | 4 + 2 | g suggested out of d and f | ||||
Bisson [9] | – | u | x | u | x | u | x | x | – | x | x | (x) | 4 + 2 | g suggested out of d and f |
Heiden and Lajoie [28] | x | – | – | x | u | u | u | x | – | x | x | (x) | 3 + 2 | Randomization process was weak |
Lajoie [79] | – | – | x | u | u | u | u | x | – | x | x | x | 2 + 3 | |
Toulotte [79] | x | u | u | u | x | – | (x) | x | (x) | 2 + 1 | a: classification in faller/non-faller; k: statistical information missing, e.g., ES | |||
You [104] | x | u | x | u | x | x | x | x | – | x | x | (x) | 6 + 2 |
Results
Classification of included studies
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Sampling (age comparison [AC], RCT, CPPD)
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Participants (number of participants, age, gender)
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Study aim
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Type of intervention and training duration
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Motor task (standing or walking) and measurement
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Cognitive task (executive control, controlled processing, processing speed, visuospatial task; cf. [14]) measurement
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Type of stimulus and stimulus–response in the cognitive task (auditory, verbal, visual, motor)
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Methodological quality (cf. Table 3).
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Measurements of motor performance: A variety of different tests and clinical assessments were used to describe motor performance while standing and walking. To examine motor performance in standing tasks, four studies [28, 29, 35, 79] used clinical tests, like the Berg Balance Scale (BBS), Timed up and go (TUG) or the Community Balance and mobility scale (CB&M). Seven studies investigated standing motor performance by the use of biomechanical assessments like force platforms or other measurements of COP sway displacements [9, 16, 17, 23, 28, 80, 93] and two studies [29, 35] used both types of testing. To observe walking performance, three studies used clinical assessments (e.g., TUG [23, 28, 104]) and five studies used measurements to gain precise biomechanical markers like gait variability, velocity, cadende, and stride length — for example, a gait mat with sensors or a kinematic system [66, 67, 79, 80, 104]. One study [23] used both kinds of testing to report walking performance.
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Complexity of the cognitive task: The majority of studies applied cognitive tasks focusing on controlled processes (n = 5; [23, 66, 67, 80, 93]) or executive control tasks (n = 4; [18, 29, 66, 104]). Three studies examined processing speed tasks [9, 28, 35] and only one study used a visuospatial task [16]. Another study did not specify the cognitive task [79].
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Stimulus–response of the cognitive task: a preference for verbal responses can be observed with most studies applying an auditory (n = 8; [9, 23, 28, 35, 66, 67, 80, 93]) or a visual cognitive stimulus (n = 3; [16, 17, 23]) with a verbal response. One study used an auditory task with a motor response [104]. Again one study did not specify the stimulus–response [79].
Description of the types of training interventions used in the included studies
General ST training
Specific ST training
General DT training
Specific Dual Task training (SDT)
Results sorted by training types
First Author | Type of intervention | Effects on ST motor performance while standing | Effects on ST cognitive performance | Effects on DT performance while standing | Effects on ST motor performance while walking | Effects on ST cognitive performance | Effects on DT performance while walking |
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Bisson [9] | GST | ↑ | n.a. | MP: – | n.a. | n.a. | n.a. |
CP: ↑ | |||||||
Hall [23] | GST | CG+EG: ↑ | n.a. | MP: CG ↑, | CG+EG: obstacle course ↑ | n.a. | MP: CG ↑, |
EG – | EG – | ||||||
CP: n.a. | CP: n.a. | ||||||
Hiyamazu [29] | GST | – | – | MP: – | n-a | n.a. | n.a. |
CP:– | . | ||||||
Lajoie [35] | GST | ↑ | n.a. | MP: – | n.a. | n.a. | n.a. |
CP: EG reaction time ↓, | |||||||
Silsupadol [66] | GST | n.a. | n.a. | n.a. | ↑ | – | MP ↑ |
CP: – | |||||||
Silsupadol [67] | GST | ↑ | n.a. | MP: – | ↑ | n.a. | MP ↑ |
CP: – | CP: – | ||||||
You [104] | SST | n.a. | n.a. | n.a. | n.a. | n.a. | MP:↑ |
CP: – | |||||||
Bisson [9] | GDT | ↑ | n.a. | MP: – | n.a. | n.a. | n.a. |
CP: ↑ | |||||||
Heiden and Lajoie [35] | GDT | ↑ | n.a. | MP: – | EG: ↑ | n.a. | n.a. |
(CB&M) | CP: ↑ | ||||||
Hiyamazu [29] | GDT | – | ↑ | MP: – | n.a. | n.a. | n.a. |
CP: ↑ | |||||||
Silsupadol [66] | GDT | n.a. | n.a. | n.a. | ↑ | ↑ | MP ↑ (DT both groups) |
CP: ↑ (VP Group) | |||||||
Silsupadol [67] | GDT | ↑ | n.a. | n.a. | ↑ | ↑ | MP ↑ (DT both groups) |
CP: ↑ (VP Group) | |||||||
Trombetti [80] | GDT | ↑ | n.a. | n.a. | ↑ | n.a. | MP: ↑ |
CP: n.a. | |||||||
Toulotte [79] | GDT | F+NF: ↑ | n.a. | MP: ↑ (both groups) | F+NF:↑ | n.a. | MP: ↑ (both groups) |
CP: n.a. | CP: n.a. | ||||||
Westlake [93] | GDT | ↑ | n.a. | MP: EG : ↑ | n.a. | n.a. | n.a. |
Dault [16] | SDT | n.a. | n.a. | MP: – | n.a. | n.a. | n.a. |
CP: ↑ | |||||||
Doumas [18] | SDT | Y+O: ↑ | n.a. | MP: ↑ (both groups) | n.a. | n.a. | n.a. |
CP: n.a | |||||||
DTC: ↓ | |||||||
You [104] | SDT | n.a. | n.a. | n.a. | n.a. | n.a. | MP: – |
CP: ↑ |
Effects of GST training on motor and cognitive performance under single-task (ST) and DT conditions
Effects of SST training on motor and cognitive performance under ST and DT conditions
Effects of GDT training on motor and cognitive performance under ST and DT conditions while standing
Effects of SDT training on motor and cognitive performance under ST and DT conditions
Summary of the main results of the training interventions and study aims
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DT motor performance while standing was improved by three of the eight included training interventions. Two of them used GDT [79, 93] and one SDT [18]. The GDT improved one leg balance in fallers and non-fallers [79] and increased postural stability after mechanical induced displacements of the COP [93]. The SDT improved postural sway on a moving force platform [18].
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DT motor performance while walking was improved by seven of the 13 interventions, either by the use of ST (n = 2 GST [66, 67]; n = 1 SST [104] or DT (n = 4 GDT [66, 67, 79, 80]) interventions. The only type of intervention that revealed no effect on DT walking performance was SDT ([104]; note that only one study is available). The main motor outcomes were improved walking parameters like cadence for GDT [79], gait variability and walking speed (GDT [66, 67, 79, 80], GST [66, 67], SST [104], and narrow walk GST and GDT [66, 67]).
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DT cognitive performance while standing was improved by five out of six studies using GST [9, 35], GDT [9, 28, 29] or SDT [16]. Positive effects were found for processing speed of auditory–verbal tasks [9, 28], a visual–verbal executive Stroop test [29] and a visual–verbal visuospatial task [16]. The SDT of Doumas and colleagues [18] did not report DT cognitive performance separately, but they found decreased DTC for an executive n-back task. Effects of SST on DT cognitive performance were not examined.
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Eight studies examined DT cognitive performance while walking. Most of the ST training studies (three studies using GST [23, 66, 67] and the study performing SST [104]) found no benefits on cognitive DT abilities. In contrast, three of the eight GDT programmes [28, 66, 67] and the SDT conducted by You et al. [104] increased the cognitive DT performance, either in an auditory–verbal processing speed task [28] or in more complex controlled processing tasks [66, 67, 104].
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ST cognitive performance while standing was only examined in two studies by the use of different types of interventions: Hiyamazu et al. [29] for GST and GDT (trail making test), Doumas et al. [18] for SDT (n-back executive control task). Again, effects of SST on DT cognitive performance were not examined.
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In sum, intervention effects on cognitive performance were less investigated (only in nine studies for DT conditions [9, 16, 18, 28, 29, 35, 66, 67, 104] and in two studies for ST conditions [29, 66]) than on motor performance. Based on the results, one might assume that there is an advantage in DT training, either GDT or SDT, to improve cognitive performance. Due to the low evidence, results have to be interpreted carefully. In addition, most studies used controlled processing tasks with an auditory–verbal stimulus–response. Thus, it is difficult to state a clear advantage or benefits of a specific task complexity or stimulus–response condition.