Can your competent/ doctor get this protocol to try on you even if it is of low quality? Or can't your doctor even manage that simple task?
Cognitive-motor dual-task training on gait and balance in stroke patients: meta-analytic report and trial sequential analysis of randomized clinical trials
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 227 (2024)
Abstract
Objective
Cognitive-motor dual-tasking training (CMDT) might improve limb function and motor performance in stroke patients. However, is there enough evidence to prove that it is more effective compared with conventional physical single-task training? This meta-analysis and Trial Sequential Analysis of randomized clinical trials (RCTs) aimed to evaluate the effectiveness of CMDT on balance and gait for treating hemiplegic stroke patients.
Methods
The databases were searched in PubMed, Web of Science, Ovid Database and The Cochrane Library, SinoMed database, Chinese National Knowledge Infrastructure (CNKI), Wan Fang database, and VIP database up to December 8, 2023. The Cochrane-recommended risk of bias (RoB) 2.0 tool was employed to assess risk of bias in trials. The statistical analysis was employed using R version 4.3.2. In addition, subgroup analyses and meta-regression were performed to explore the possible sources of heterogeneity. The evidence for each outcome was evaluated according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Working Group criteria. The Copenhagen Trial Unit's Trial Sequential Analysis (version 0.9.5.10 Beta) was used for sequential analysis.
Results
Seventeen randomized clinical trials (RCTs) (n = 751 patients) were included. The results demonstrated that cognitive-motor dual-task training (CMDT) might be beneficial on stroke patients on Berg Balance Scale (BBS) (MD = 4.26, 95% CI 1.82, 6.69, p < 0.0001) (low-quality evidence). However, CMDT might not affect Time Up and Go test (TUG) (MD = −1.28, 95% CI −3.63, 1.06, p = 0.284); and single-task walking speed (MD = 1.35, 95% CI −1.56, 4.27, p = 0.413) in stroke patients (low-quality evidence). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) results indicated that all findings were very low to low certainty. Trial Sequential Analyses demonstrated larger sample sizes are required for confirming our findings.
Conclusion
Cognitive-motor dual-task training (CMDT) compared with conventional physical single-task training might be an effective intervention for improving static balance function in stroke patients (low-quality evidence), which should be interpreted cautiously due to heterogeneity and potential biases. Nevertheless, further research is required to support the abovementioned findings.
Trial Registration This protocol was registered in PROSPERO (CRD42023490530).
Introduction
Stroke is an acute cerebrovascular disease that can cause cognitive, motor, and balance dysfunctions [9, 77]. These dysfunctions can significantly impact the patient's quality of life and are leading causes of disability and death [44]. Motor dysfunction that affects the ability to walk is a significant factor in the reintegration of stroke survivors into social activities. Evidence-based medicine confirms that early post-stroke rehabilitation is an effective method to reduce disability rates and improve patients' limb dysfunction [13]. Stroke patients are typically treated with early rehabilitation under single-task (ST) conditions [69]. This approach improves patients' limb function [69]. However, research has shown that only 60%-80% of stroke patients who have undergone single-task training can walk independently [69]. Additionally, A significant proportion of patients continue to exhibit reduced gait function and an increased risk of falls following their discharge from the hospital.
Cognitive-motor dual-task training (CMDT) involves performing cognitive tasks alongside motor training [70, 85, 87], a novel rehabilitation tool to help stroke patients. Studies of the neural bases of the effects of CMDT have shown that there was an increase in brain activity during dual-task (DT) especially in the pre-frontal cortex (PFC) [5, 36]. A meta-analysis of thirteen studies that utilized fNIRS to investigate cognitive challenges during dynamic balance control found that dual-tasking resulted in increased pre-frontal cortex activation compared with single-tasking [79]. It achieves this by accelerating central neural transduction, activating the higher cortex of the brain, optimizing the allocation of attentional resources, and facilitating neurological remodeling, which simulates a real-life environment for rehabilitation in both motor and cognitive domains [71, 75, 81]. Motor training is thought to promote synaptic plasticity and cell proliferation. In contrast, cognitive training seems to direct these newborn neurons into connection with pre-existing neural networks [6, 18, 25], which can increase the speed of information processing. CMDT can effectively strengthen the functional network connections between cognitive and motor regions, activating the cerebral cortex and facilitating the remodeling of brain functional networks. [56] CMDT enables the reorganization of cognitive task allocation strategies, optimizes the allocation of cognitive resources, increases coordination between tasks, and increases the flexibility of resource allocation [11].
There are three main underlying theories of cognitive-motor dual-task training (CMDT): the bottleneck, the cross-talk, and the capacity-sharing theory. The bottleneck theory indicates that encompassing the process of task training is sequential, not parallel [58]. the cross-talk theory postulates that if two tasks are from the same cognitive domain and neuronal populations in the brain, they will not interfere with each other [52]. the capacity-sharing theory postulates that humans have limited cognitive capacity and that doing two tasks simultaneously decreases performance on one or both [27].
Cognitive functions include attention, working memory, and executive ability. The interaction between these two executive functions, working memory and attention, could promote neurological rehabilitation outcomes. Hard cognitive tasks (HC) distracted more attention and reduced attention to conscious postural control in stroke patients [28]. One possible explanation may be that cognitive tasks require more complex mental processes such as working memory, mental tracking, and decision-making [2]. Working memory tasks are designed to retain things in the mind to perform complex tasks such as reasoning, understanding, and learning [3]. It has been found that working memory requires increased presynaptic glutamate release and changes in postsynaptic glutamate receptor activity [65]. The bottleneck theory assumes that all tasks involving stimulus–response associations depend on a central processor, i.e., only one task can be processed at a given moment, while the other waits, i.e., the central processing stages of the two tasks cannot overlap. This means that the central processing stages of the two tasks cannot overlap, thus creating a central processing bottleneck in the secondary task. Although the bottleneck theory emphasizes that the tasks are processed in a strict serial order, and this serial processing model will include some primitive requirements and possibly additional processing demands, it has also been found that these additional mental processes are closely related to working memory [53]. Attention is the ability of an individual to focus and concentrate on perception, thought, and behavior selectively. [66].Attention is often considered to be the basis of cognitive functioning. The capacity-sharing theory suggests that two tasks can run in parallel but compete for limited processing resources, resulting in reduced performance. The extent to which a single task is affected during dual-tasking ultimately depends on how one allocates attention to the corresponding task, so we must match appropriate attentional resources to each task [68]. During dual-task training, the decline in cognitive or motor performance ability in the cognitive-motor dual-task training (CMDT) group at the beginning, which gradually diminished with the prolongation of the treatment time, may suggest that the patients were progressively able to allocate their attentional resources appropriately during repeated training. So that the speed of synaptic signaling of brain neurons is accelerated, attention and executive function can be significantly improved [42].
After comparing the capacity-sharing theory with the bottleneck theory, it is easy to find that the two theories have different focuses. The former believes that there is sharing in multitasking and that tasks can be processed simultaneously so that attentional resources can be allocated appropriately. The latter, on the other hand, believes that there is no sharing in task processing and that tasks are processed in a strict order of priority, which also requires further research to clarify the mechanism of multitasking.
A previous meta-analysis demonstrated that cognitive-motor dual-task training (CMDT) improves balance, gait, and upper limb function in patients with chronic-phase stroke. However, the sample size was relatively small, and the source of heterogeneity was not explored. Performing dual tasks requires more cognitive aspects including attention and working memory [83], which requires meta-analyses to explore whether different elements of cognitive domains impact neurorehabilitation to meet the mental needs of stroke patients. To further elucidate the benefits of CMDT on balance and gait function in stroke patients, this study evaluated the clinical efficacy of CMDT based on moderator analysis and Trial Sequential Analysis (TSA) [78]. Furthermore, the study aimed to determine the necessary sample size.
A lack of precision characterizes the results of meta-analyses with sparse data. Such meta-analyses are typically updated periodically to obtain additional experimental data, necessitating repeated significance tests. The repetition of tests on accumulating data increases the overall risk of a type 1 error occurring. Applying Trial Sequential Analysis necessitates meticulous consideration of statistical significance thresholds, trial size, heterogeneity, and potential random errors. This approach necessitates the calculation of the requisite information to ascertain the optimal sample size required to determine a specific effect size and achieve a specified level of statistical power. Trial Sequential Analysis (TSA) is a novel tool that can reduce the risk of inflated type one error to verify the robustness of the findings [78]. Therefore, to extend previously available evidence, this study employed meta-analysis to evaluate and analyze the results of randomized controlled clinical trials of cognitive-motor dual-task training (CMDT) applied to post-stroke gait and balance disorders published by December 8, 2023. The aim was to provide a basis for the future clinical practice of cognitive-motor dual-task training in gait and balance recovery in stroke patients.
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