Introduction

More than 2 million new stroke cases reported annually in China, and the overall incidence rate is on the rise1 Stroke is characterized by a high incidence rate, disability rate, recurrence rate, and mortality2 Motor and cognitive impairments are common consequences of stroke, with nearly 50% of stroke patients experiencing balance function deficits three months after the stroke, which significantly affects functional independence and quality of life3 In recent years, the concept of cognitive-motor interference, which is closely related to daily activities, has gained increased attention in the field of rehabilitation medicine4 Numerous studies have indicated that stroke patients exhibit a more significant decline in balance and gait performance during dual tasks involving cognitive-motor interference5.

Balance control is increasingly recognized as a multifaceted process involving the integration of both motor and cognitive networks6 Balance control encompasses two dimensions: orientation and stability. Orientation entails the cognitive processing of information from proprioceptive feedback, the vestibular system, and visual input. Stability, on the other hand, refers to the ability to maintain the amplitude of the center of gravity swing and keep it within the support surface despite spontaneous activation or external interference7 Notably, there is a close association between executive function, posture control, and fall risk8 In real-world functional activities, continual attention to environmental cues is necessary to quickly respond and prompt restoration of balance following posture interference. Thus, it is unsurprising that advanced cognitive functions such as attention, execution, and dual-task processing abilities are essential for optimal balance control9 Due to central and limb dysfunction, stroke often manifests abnormal posture control strategies, including increased body swing amplitude, delayed or reduced expected posture adjustment, asymmetrical weight-bearing, and gait instability, particularly in dual-task situations10,11 Currently, many studies evaluating the impact of rehabilitation training on balance function in stroke patients rely on assessment scales12 However, the ability to maintain the center of pressure (COP) is a crucial systemic parameter in balance control, and the existing evaluation scales fail to provide this aspect13 Our study employs functional performance assessments, scales, and COP to explore the balance performance in stroke patients during both single-task and dual-task conditions in clinical rehabilitation. Given the crucial role of executive function and balance control ability in stroke prognosis, the objective is to examine whether our proposed training intervention has the potential to enhance both the balance and executive function, leading to better motor control.

As evidenced by extensive literature,14,15 the importance of cognitive processes and motor skills in balance control makes the motor-cognitive training based on a “guided plasticity facilitation” framework show great potential16 The mechanisms underlying the synergistic effect of motor-cognitive training can be primarily attributed to two aspects. From a neurobiological standpoint, motor training can facilitate neuronal activity and enhance synaptic plasticity, while cognitive training can guide long-term synaptic plasticity and regulate neural circuits17 Moreover, from the perspective of brain structure and function, the shared neural network involved in motor and cognitive processes promotes enhanced functional coherence within the brain network, and the activation of distinct functional networks facilitates the refinement of specific connections between them18 Motor-cognitive training encompasses three forms: sequential, simultaneous, and interactive. Among these, interactive motor-cognitive training exhibits the most pronounced benefits for enhancing motor ability related to stroke recovery19 But current research on interactive motor-cognitive training predominantly relies on virtual reality systems,20 leaving limited clinical training methods available for this innovative approach. Therefore, a comprehensive review encourages researchers to develop novel, efficient, and clinically applicable methods of interactive motor-cognitive training21.

To address this gap, this study proposes a Computerized Quadrato Motor Training (CQMT)—an adaptation of Quadrato Motor Training (QMT), a protocol originally developed by Patrizio Paoletti to integrate posture-related executive tasks with motor tasks22 CQMT digitally enhances QMT by adapting the speed of computer commands to individuals’ reaction times, thereby retaining the objective and progressive feedback inherent to VR while eliminating high costs and spatial constraints23 However, there is a lack of research investigating its potential utility in stroke rehabilitation.

In conclusion, while interactive cognitive-motor training has gained research traction, its clinical implementation often relies on complex equipment like VR, lacking simple and accessible clinical training approaches. In this context, QMT training, a novel approach that integrates cognitive elements into motor skills, holds promise for clinical application. However, it has not been tested in stroke patients. To address this gap, this study proposes CQMT and applies it to stroke patients. By progressively reducing instruction time to challenge patients’ reaction times, CQMT not only maintains the objectivity, personalization, and progressive nature of VR training,23 but also enhances clinical practicality. Considering stroke patients often experience balance and executive function deficits, QMT’s cognitive components are related to posture control,24 which may outperform conventional motor training. Therefore, our study aims to compare the effects of CQMT on (a) balance function (primary outcomes) and (b) executive function (secondary outcomes) in comparison with exercise training and conventional training. This study hypothesized that both groups would improve their balance performance, whereas CQMT would enhance a higher degree of balance performance and executive performance, aligning with the viewpoint regarding the synergistic effects of interactive motor-cognitive training25.

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