Cognitive challenges to mobility training · Cognitive challenges to mobility training 1 Margaret...
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Transcript of Cognitive challenges to mobility training · Cognitive challenges to mobility training 1 Margaret...
Cognitive challenges to mobility training
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Margaret Mak PT, PhDDepartment of Rehabilitation SciencesThe Hong Kong Polytechnic University
Dynamic Control of Gait (1)
X Walking difficulty is one of the cardinal signs that persist despite optimal medication.
X Higher risk of immobility and FALLS (Ashburn et al., 2001a, Post et al., 2007)
X 45-50% of falls occurred in walking (Ashburn et al., 2008)
Slower velocity,longer double support
Ç cadence,not stride length in fast walking
Èpush-off , foot clearance, & arm swing
(Hausdorff et al., 1998, Morris et al., 2001, Sofuwa et al. 2005, Behrman et al., 1998)
Dynamic Control of Gait (2)
X Gait is more affected with Ç task complexity or cognitive demand: È gait speed , stride length & stride to stride variability (Plotnik et al., 2011a,b)
Effect of motor dual task on gait in PD patients - ↓ Gait speed and/or stride length
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Study Task
Bond & Morris (2000) Tray with glasses
Canning (2005) Tray with glasses
Galletly and Brauer (2005) Button press
Rochester et al. (2008) Tray with 2 cups of water
Chawla et al. (2014) Coin transfer
Effect of cognitive dual task on gait in PD patients - ↓ Gait speed and stride length
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Study Task
Rochester et al. (2004) Memory task
Brown et al. (2009) Serial subtraction by 3
Hackney and Earhart (2009) Serial subtraction by 3
Plotnik et al. (2011) Serial subtraction by 3 & 7
Wild et al. (2013) Phoneme counting, Serial subtraction by 3
Stegemöller et al. (2014) Serial subtraction by 3
TreatmentXAvoid dual task
XTrain dual-walking task
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Review paper. Valerie et al. Parkinson Dis 2012
Training approaches
X Improve automaticity – balance, gait ability
X Improve cognitive functions - set-shifting ability…
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Available literature in dual-task gait training
X Dual-task gait training with priority given to walking - ↑ gait velocity and stride length in both single- and dual-task conditions (Canning 2005), retention for 30 min (Fok et al. 2010)
X Dual-task gait training with equal attention to both tasks -↑ gait velocity and stride length in dual-task walking, with retention for 30 min (Fok et al. 2010)
X Multi-task training with instruction of divided attention, ↑ gait velocity with retention for 3 weeks (Canning 2008)
X Limitations: X Retention period is short
X Most of the tasks are not functional, Generalization??
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Treatment approaches:
XWho can be trainedXWhat task can be addedXSafeXEffective
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9Improve automaticity – balance, gait ability, then add secondary task
Who can be trained?
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Study – dual motor task UPDRS HY Task
Bond & Morris (2000) 13^ - Tray with glasses
Canning (2005) III-20 2.1 Tray with glasses
Galletly and Brauer (2005) 14 Button press
Rochester et al. (2008) 33 - Tray with 2 cups of water
Chawla et al. (2014) - 2.2 Coin transfer
^Webster scale
Who can be trained?
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Study – dual cognitive task UPDRS HY Task
Rochester et al. (2004) - 2.7 Memory task
Brown et al. (2009) 28 2.3 Serial subtraction by 3
Hackney and Earhart (2009) 28 - Serial subtraction by 3
Plotnik et al. (2011) 35 2.1 Serial subtraction by 3 & 7
Wild et al. (2013) III-16 1.9 Phoneme counting, Serial subtraction by 3
Stegemöller et al. (2014) 37 2.1 Serial subtraction by 3
Who can be benefited from training?
X PD with mild disability level – less balance and gait problems, less cognitive impairment, better motor learning ability
X Non-fallers, single fallersX Train balance abilities firstX Add cognitive challenge to walkingX Those with moderate level of severity and frequent
fallers – safety, avoid dual tasks, specific strategies such as cues, cognitive movement strategies, to focus on the motor tasks.
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What task can be added?
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Study UPDRS HY Task
Bond & Morris (2000) 13^ - Tray with glasses
Canning (2005) III-20 2.1 Tray with glasses
Galletly and Brauer (2005) 14 Button press
Rochester et al. (2008) 33 - Tray with 2 cups of water
Chawla et al. (2014) - 2.2 Coin transfer
^Webster scale
What tasks can be added?
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Study UPDRS HY Task
Rochester et al. (2004) - 2.7 Memory task
Brown et al. (2009) 28 2.3 Serial subtraction by 3
Hackney and Earhart (2009) 28 - Serial subtraction by 3
Plotnik et al. (2011) 35 2.1 Serial subtraction by 3 & 7
Wild et al. (2013) III-16 1.9 Phoneme counting, Serial subtraction by 3
Stegemöller et al. (2014) 37 2.1 Serial subtraction by 3
Dual-task gait training – tasks usedXCounting backward (Canning 2005, Fok et al. 2010)
XCognitive tasks: counting backwards by twos and threes, memory recall, generating category lists (fruit, sports), simple arithmetic task (Canning 2008)
XMotor tasks: doing up buttons, carrying a plate with a glass on top and transferring coins between pockets or objects between hands (Canning 2008)
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Most of the task are not functionalAll indoors, no community involvement
What task can be added?
X Functional tasks, include outdoors
X Fall characteristicsX ABC scales:
complex community tasks
X Lower marks esp for outdoor activities
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Training protocol – Multi-system balance and mobility training
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• All balance domains, indoor training• Improve automatic control of balance
and gait• 4 weeks
Balance and mobility training
• Outdoor, shopping malls• Spare attention for the added task• 4 weeks
Add complexity
and dual tasks
Home exercises for 6 more months in parks and malls
Subject characteristicsDemographic data EXP (n=41) CON (n=39) p value
Age 59.4±9.0 62.6±8.9 0.109
Gender (male: female) # 25:16 21:18 0.519
PD duration (years) 7.1±4.3 5.6±3.8 0.103Body Mass Index 22.8±3.4 22.7±3.1 0.861
Hohen & Yahr Stage 2.5±0.3 2.4±0.3 0.198
Non-fallers: fallers ratio # 32:9 36:3 0.074
MDS-UPDRS motor score 29.6±10.4 31.3±11.1 0.362
Non-freezers: freezers ratio # 17:24 16:23 0.968
Daily levodopa equivalent dosage (LED mg) 409.3±288.2
320.8±391.0 0.251
Attendance at training (%) 96.3±5.8 94.2±8.0 0.179
Change of LED form Pre to FU12m 10.9±61.9 27.8±83.2 0.352
6m exercise compliance at FU (no. of completer: non-completer) #
28:13(68%)
21:18(54%)
0.185
# chi-square test20
Postural & Flexibility Ex
Functional Training
Indoor Training
Square Stepping Exercise
Balance Dance with
Music
ModifiedWing Chun
SG
SO
PR
APA
LOSBC
POSTURALCONTROL
Square stepping
3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4 3 1 2 4
3 2 4 5 1 6 3 2 4 5 1 6 3 2 4 5 1 6 3 2 4 5 1 6 3 2 4 5 1 6
7 1 2 8 3 5 6 4 7 1 2 8 3 5 6 4 7 1 2 8 3 5 6 4 7 1 2 8 3 5 6 4 7 1 2 8 3 5 6 4
Basic Intermediate Advance
↑ Complexity of the learnt task
• Practice balance dance and wing chun in outdoor environment:– Uneven ground– Gentle slope
• Increase movement speed, step size, and complexity
• Increase perturbation speed
Add cognitive challenge• Attention shift during walking - change in
direction or motor plan• Add secondary tasks• Fall prone activities• Ensure safety during practice
Response to perturbation
Obstacle crossing
↑ Movement complexity
Fall-prone activities training
In and out elevator
In and out escalator
Add complexity dual task
Pull and push door
Bio constraint
Limit of stability
Anti post adjust
Post response
Sen orientation
Gait stability
Effects: Improve balance and dual-task mobility in both short- and long-terms
Injurious Falls Outcome Post FU12m(a) Ratio of non-injurious fallers: injurious fallers EXP (n=41) 0 12:5
CON (n=39) 0 3:9Risk ratio NA 0.392Odds ratio (95% CI) NA 7.2
(1.35-38.33)Likeihood ratio NA 6.075
Pearson χ² NA 5.855
p NA 0.025*
(b) Ratio of injurious falls requiring healthcare services to all falls (%) EXP (out of 31 falls) 0 19%
CON (out of 20 falls) 0 50%
Odds ratio NA
4.2(95% CI) (1.194-14.541)
p NA 0.021*
(c) Landing with forearm and/or hand in all falls (%) EXP 0 48%
CON 0 20%p NA 0.041*
*p < 0.05
Abbreviations: CI, Confidence interval; CON, the control group; EXP, the experimental group; Post, post-training; FU12m, 1-year follow-up
Reduce injurious fall risk at 12 months follow-up
Manuscript under preparation
Improvement in BESTest scores and dual-task gait
Short-term effects on balance and dual-task gait performance
9 Task-specific training: target all 6 balance domains
9 Context-specific training: match the exercise learnt with daily environment
9 Progressive challenges: start with indoor ex. to learn essential balance skills, then practice complex tasks e.g. fall-prone functions and dual-task gait activities outdoors
9 ↑ attentional abilities to the environment
9 Positive feedback from PTs serves as motivational rewards
41(King & Horak, 2009, Nieuwboer et al. 2009, Morris et al. 2010, Smania et al. 2010, Shen & Mak 2012, 2014, Abbruzzese et al. 2016)
Balance Dance
Square Stepping
Wing Chun
Mobility & strength ex.
Flexibility, Mobility & strength ex.
Balance Dance
Balance Dance
Wing Chun
Square Stepping
Long-term effects on balance and dual-task gait performance
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Improvement in balance, gait & functional outcomes beyond treatment completion, which may imply neural neuroplasticity
(Ellis et al. 2011; Shen et al. 2015)
Training
• Goal-directed interventions on all balance domains• Task- and context-specific• Home exercise guidelines and video demo
Rewards
• Short-term gains to encourage further practice Æskill retention & consolidations
• Use of free-of-charge venues for practice
Behaviour
• Higher % of EXP group completed suggested home ex.
• Establish positive exercise behaviour
Long-term effects on fall outcomes• The first study to report a reduction of injurious fallers
among NFs & SFs after multi-system balance training• EXP group:
– Improved balance and fall-prone functional performance – Better abilities in handling fall-prone situations in outdoor
environment– Use UL more in landing possibly due to practice of arm
responses with Wing Chun• Descent movement with outstretched arms may absorb
some impact energy of falls to other parts of the body (Fasano et al. 2012)
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Injurious fall risk
SummaryXMulti-system balance and dual-task mobility
training enhances balance and dual-task walking performance in PD NF & SF
XReduce injurious fallsX Improvement in functions beyond treatment
completion may imply neuroplastic changes XNot clear whether cognitive training can
improve dual-task mobilityXCognitive training + mobility training may
benefit PD with freezing of gait (Peterson et al. 2016)44
X Christin ShenX Irene WongX Chloe ChungX Hong Kong PD
FoundationX Li Ka Shing FoundationX SK Yee Foundation
Neural Control and Balance Laboratory