ROLE OF DUAL TASK TRAINING IN PATIENTS WITH PARKINSON’S DISEASE.

PRESENTED BY- ABDUL BASIT NEUROLOGICAL PHYSIOTHERAPY

abdulbasit0876@gmail.com

• Parkinson’s disease is a chronic, progressive and neurodegenerative disorder affecting over 4 million people worldwide.(Braver et al 2011)

• Crude prevalence rate of Parkinson’s disease in India is 6-53/100000 (Devi et al 2004)

• Pathologically, loss of nigrostriatal dopamine in the basal ganglia, causes decreased automaticity of movement and increased attention for movement.

• Motor symptoms in Parkinson’s disease are bradykinesia, resting tremors, rigidity, postural instability and gait impairment.

• Non motor symptoms such as sleep disorders, cognitive impairment, depression, and fatigue some of which are the adverse effects of dopaminergic medications. (Hubert and Fernandez 2012).

• The pharmacological therapy used for managing symptoms in Parkinson’s disease is levodopa which provides symptoms management in early years, but after some years it develops adverse effects in the form of dyskinesia and motor problems.

• Cognition and attention problems , depression, fatigue, and postural balance were significantly affected walking speed and the functional tasks in normal ADLs.

• Doing more than one task at a time is common disabling problem experienced by Parkinson’s disease patients.

• Gait and Balance becomes more deteriorated in these individuals when they simultaneously perform motor task.(Braver et al).

• In normal individual there is normal division of attention to many stimulus at a time but this ability is impaired in patients with Parkinson’s disease leads to slowness of one or both the tasks, affecting quality of daily life.

• People with Parkinson’s have difficulties in doing movement in a sequence

• these patients give preference to cognitive task over motor task leads to serious difficulties in normal living of these peoples

• Gait impairments are main part of rehabilitation because it is commonly affected and its leads to several problems in Parkinson’s patients• The number of falls tend to increase, just as

the patient dependency of others, leading to poor self concept, self esteem, and quality of life (Eusterbrock and Shumway cook 2012).• Yogev et al, 2005 studied that gait speed

decrease during dual-task in both Parkinson’s disease and healthy older adults control groups.

• This slowness of gait is a protective strategy in response to increased attention of concurrent task.

• In persons with Parkinson’s disease gait automaticity becomes an attention demanding task.

• In Parkinson’s patient, There is increased gait variability i.e. stride time variability and swing time variability , decreased automaticity which are associated with falls in patients with Parkinson’s disease .

• Blown et al (2001) suggested that while healthy control give priority to postural task at the cost of making mistake in cognitive task. Patients with Parkinson’s disease do not use this strategy and this might increase their risk of falling.• Freezing of gait is inability to generate

effective stepping. It occurs at gait initiation, during turning, in narrow spaces, under stressful or emotional conditions and when patients are asked to perform dual tasking.

• Cognitive function affects gait variables like stride length, gait velocity and executive function related to step width.

• Specific cognitive functions such as set shifting, dividing or alternating attention and response inhibition may be particularly relevant to dual-task walking.

• People with cognitive deficits limit compensation for gait impairment using cognitive strategies like taking big steps while walking.

• The proposed mechanism responsible for dual task interfere includes central capacity sharing model and bottle neck model. (O shea et al 2002)

• Bottle neck theory proposed that when two task are similar in their nature and utilize common neuronal resources, a bottle neck will be created in the information processing that reduce performance.

• Capacity sharing model suggested that performance of two attention demanding tasks reduces the functioning of one or both task, if capacity limit are exceeded, regardless of the specific nature of the task.

• Patients with Parkinson’s disease require more cerebral region involvement when performing automatic movements to overcome Basal ganglia dysfunction

• There is no consensus among researches whether dual tasking is advised to improve performance or it should be avoided by the people with Parkinson’s disease for safety concern.

• Many Studies done which supports dual task training and improves dual task performance in Parkinson disease patients

• Canning et al, 2005 investigated the effects of directing attention on walking performance under dual-task conditions in people with Parkinson’s disease.

• Subjects in first experimental group asked to pay attention to walking while another experimental group asked to pay attention to tray with glass while walking.

• Subjects walk faster with longer strides while instructed to pay attention towards walking without any adverse effects of carrying tray with glasses when compared to controls.

• This study suggests that specific instructions can be used to enhance performance in dual-tasking with mild to moderate Parkinson’s disease.

• Fok et al, 2010 conducted study on gait prioritization strategy on walking in people with Parkinson's disease.

• There were 6 subjects in treatment group who received 30 minutes therapy to prioritize attention to take big steps while performing serial 3 subtractions.

• Baseline measurement made in subjects with single task and double task.

• Stride length and gait velocity increased when participants pay attention to take big steps.

• Rochester et al,2011 examined effects of cueing therapy in improving gait.

• Cueing therapy consists of walking in time to metronome beat to correct step amplitude and step frequency during functional activities.

• Cue was aimed to improve temporal and spatial parameters of gait.

• Cueing therapy significantly improved single and dual-task walking speed, step amplitude, single task step frequency.

• The results provide promising evidence for role of cueing therapy for symptom management

• Lohnes et al, 2011 studied the impact of attentional, auditory, and combined cues on walking during dual-task performance in patients with Parkinson’s disease.

• It includes the effect of cue type and gait complexity on gait with Parkinson’s disease.

• Gait velocity and stride length increased in patients with attentional cues but not with auditory cues.

• During walking while performing secondary cognitive task, attentional cues may help facilitate a longer step length.

• Kelly et al, 2012 examined the effect of attention on dual-task walking with cognitive task or motor tasking people with Parkinson’s disease.

• Subjects walked faster when focus on walking,while focused on walking Subjects decreased cognitive performance.

• Result of the study states that after instructions to walking there is decrement in cognitive task. Instructions influenced both walking and cognitive task performance.

• This study shows that dual-task performance is flexible and can be modified by instructions in people with Parkinson’s disease.

• Fok et al, 2012 examined effect of dividing attention between walking and performance of secondary cognitive task in people with 30minutes Moderate Parkinson’s disease.

• Participants in training group (n=6) received 30 minutes attention training of taking big steps while simultaneously performing serial 3 subtraction. No such training given in control (n=6).

• Improvement in gait velocity and stride length was found in training group. It concluded divided attention used as a strategy to improve slow and short stepped gait under dual-tasking

• Killane et al, 2015 examined the effects of dual motor cognitive virtual reality training on dual task performance in Freezing of gait.

• They included 20 Subjects 13 with freezing of gait and 7 without Freezing of Gait.

• The intervention consists of virtual reality maze through which subject navigated by stepping in place on balance board under time pressure combined with cognitive task.

• After post intervention there was significant improvement in dual task cognitive and motor parameters, improve freezing of gait.

• Patients with Parkinson’s disease uses higher brain centers like cortex to maintain balance over diseased basal ganglia so motor and cognitive function of dual task are compromised.

• Dual-task training should be considered as part of the rehabilitation process of these patients (Wu and Hallett 2009).

• In cognitive attention training, subjects who directed to maintain big steps had better performance in gait variables than controls

• Gait prioritization used as compensatory tactic to manage slow and short footsteps during dual-task walking and there is no decrement in the performance of concurrent motor task.

• Attentional resources in these patients are not as limited as previously proposed.

• External cueing in improving gait speed and stride length while performing functional tasks. External cueing improves automaticity of Gait.

• Cueing therapy significantly improved walking speed, step

amplitude, and step frequency. Improved dual task provide evidence of increased automaticity and motor control.

• Virtual Reality make allows training in different environments, while encouraging patients to perform numerous repetitions of the training tasks under well-controlled conditions.

• The VR system is used to improve gait and walking stability in Parkinson’s patients, reduce fall risk, and have greater effects on cognition and attention.

• Lee et al, 2015 showed virtual reality significantly improved obstacle crossing performance and dynamic balance in Parkinson’s disease.

• Dual-task training with instructions to divide attention equally between walking and the concurrent cognitive task also improved dual-task gait speed and stride length (Fok et al,2012).

• Strategies including dual-task training include external cueing, cognitive or attention based strategies and dual task gait training leads to improved gait speed and stride length in mild to moderate Parkinson’s disease.

• These studies give promising role of the dual task training in improving dual task performance in Parkinson disease patients.

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