Author: Poon, Wai Yee
Title: Training dual-task balance and walking in people with subacute stroke
Advisors: Pang, Marco (RS)
Degree: DHSc
Year: 2019
Subject: Hong Kong Polytechnic University -- Dissertations
Cerebrovascular disease -- Patients -- Rehabilitation
Cerebrovascular disease -- Physical therapy
Motor ability
Department: Faculty of Health and Social Sciences
Pages: xix, 191 pages : color illustrations
Language: English
Abstract: Background: Stroke survivors often face great challenges in community ambulation after discharge from hospital. Functional ambulation in the community setting requires the ability to maintain balance while handling other attention-demanding tasks. Although dual-task performance has been quite well studied in chronic stroke, little is known about dual-task balance and/or walking performance during the subacute period after a stroke. Insight into these patients' dual-task performance would be instrumental in the formulation of timely and appropriate rehabilitation programs to improve their dual-task walking performance and better prepare them for community living. Objectives: This study had two objectives. The first was to examine the characteristics of dual-task balance and walking performance and the dual-task interference patterns among community-dwelling adults with subacute stroke, as compared with a group of age-matched control subjects without stroke history. The second objective was to explore the feasibility and effectiveness of a dual-task balance and walking training program improving dual-task standing balance and walking performance in people with subacute stroke. Design: The study involved two phases. Phase I was a cross-sectional study, while phase II was a pilot randomized controlled study. Patients and methods: In phase I, 62 participants, including 32 in the subacute period after a stroke (mean age, 64.8 ± 8.9 years) and 30 healthy age-matched adults (mean age, 63.1 ± 9.1 years) performed four balance/mobility tasks (standing with eyes open, standing with eyes closed, walking 10 m, and crossing obstacles) and three cognitive tasks (verbal fluency, serial-3 subtraction, and an auditory stroop task) in single-task and dual-task conditions. The dual-task costs of motor and cognitive performance were computed to evaluate the degree of dual-task interference in each testing condition. In study phase II, 32 stroke patients were randomly allocated into one of the three groups: the dual-task group (n=11), the single-task group (n=10), and the control group (n=11). The participants in each group received their respective exercise training during two 60-minute sessions per week for 8 weeks. The dual-task cost of the motor and cognitive performance under various dual-task conditions and the score on the Activities-specific Balance Confidence Scale were measured at baseline, within 1 week of completion of training, and 8 weeks after training. Data on fall incidence were collected via a monthly phone call for 2 months after the end of the 8-week intervention period. The feasibility of the dual-task training program was assessed according to the participants' feedback on the program after the training was completed and according to their adherence to the training program.
Results: In study phase I, it was found that regardless of the cognitive task used in the testing protocol, the addition of a cognitive task caused a significant decline in the performance of the 10-m walk and the obstacle crossing tasks relative to the single-task condition, which led to a substantial motor cost. A substantial cognitive cost, indicated by a significant reduction in the correct response rate (CRR), was observed for the serial subtraction and verbal fluency tasks when performing the 10-m walk and obstacle crossing tasks in the dual-task condition. The combination of a substantial motor cost and cognitive cost in the above testing conditions led to a mutual interference pattern. In contrast, when the standing balance tasks were performed in dual-task condition, there was no significant motor cost, but the CRR showed significant deterioration, leading to a motor-related cognitive interference pattern. In study phase II, the dual-task training program was found to induce a significant treatment effect on reducing the motor cost when the obstacle crossing task was combined with the verbal fluency task, relative to the single-task training and upper limb exercise training (F=2.918; p=0.029; ηρ2=0.168). The reduction in the motor cost remained significant at the 8-week follow-up visit (p<0.05). In addition, dual-task training tended to have a similar treatment effect for the dual-task condition of combining the obstacle crossing task with the serial subtraction task, with marginal significance (F=2.740; p=0.053; ηρ2=0.159). The cognitive cost remained unchanged after training, which indicates that the dual-task training program resulted in a real improvement in the dual-task walking function without compromising the dual-task cognitive performance. Regarding the program's feasibility, none of the participants reported any adverse events during the training period, and the attendance rate was high, with no significant differences across groups. Conclusions: This study showed significant differences in the severity of dual-task interference between people with subacute stroke and the healthy control group. The degree of dual-task interference varied with the type of balance/mobility and cognitive tasks performed. The pilot dual-task training program is feasible, safe, and effective in reducing dual-task interference in certain dual-task walking conditions in community-dwelling stroke patients in the subacute period. Clinical and Research Implications: The results of the projects in this thesis fill an important gap in our knowledge of stroke rehabilitation. These findings will be useful in informing the design of a dual-task assessment protocol for stroke patients during the subacute period. This study also provides preliminary evidence that a dual-task training program can reduce cognitive-motor interference in dual-task walking conditions in community-dwelling stroke patients during the subacute period and provide insights into the design of a dual-task intervention program for these patients.
Rights: All rights reserved
Access: restricted access

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