7

Comparison of dual task specific training and conventional physical therapy in

ambulation of hemiplegic stroke patients: A randomized controlled trial
Muhammad Iqbal1, Aatik Arsh2, Syed Muhammad Hammad3, Ijaz Ul Haq4, Haider Darain5

Abstract
Objective: To compare the effectiveness of dual task specific training and conventional physical therapy
in ambulation of patients with chronic stroke.
Methods: The randomised controlled trial was conducted at the Habib Physiotherapy Complex,
Peshawar, Pakistan, from January to August 2017, and comprised patients with chronic stroke. The
patients were randomly assigned to two treatment groups. Group A received dual task training, while
Group B received conventional physiotherapy. Dual task training included activities such as slowly
walking backward, sideways, and forward on a smooth surface while holding a 100gm sandbag. The
conventional physiotherapy included mat activities, stretching and strengthening exercises and gait
training. Pre-test and post-test data was taken for both spatial and temporal variables for both groups
using Time Up and Go Test and 10-meter walk test. Step length, stride length, cycle time and cadence
were also calculated before and after treatment. SPSS 23 was used to analyse the data.
Results: Of the 64 patients, there were 32(50%) in each of the two groups that both had 17(53%) males
and 15(47%) females. Mean age in Group A was 58.28 ± 7.13 years, while in Group B it was 58.87 ± 6.13
years. Baseline parameters had no significant differences between the groups (p>0.05). Post-treatments
scores revealed significant improvement of spatial and temporal variable of gait, 10-meter walk,
cadence, step length, stride and cycle time in Group A compared to Group B (p<0.05 each).
Conclusion: Conventional physical therapy and dual task training effectively improved gait ability of
chronic stroke patients, and the latter showed significant improvement in all spatial and temporal gait
variables compared to former.
Keywords: Conventional, Physiotherapy, Dual task, Gait, Stroke. (JPMA 70: 7; 2020).
https://doi.org/10.47391/JPMA.10443

Introduction The mortality of stroke is higher in low and middle income

Cerebrovascular accident (CVA) is the leading cause of countries (LMICs) and in the developing countries. 6
morbidity and mortality (16.5%) and is associated with Females have a higher CVA risk compared to the males.7
incredible healthcare costs worldwide.1 An estimated $27 The occurrence of recurrent stroke or transient ischaemic
billion is the annual economic costs of stroke in 27 stroke among stroke survivors is 30%.8 There will be an
European countries in which the direct cost is $18.8 billion increase by 50% in CVA incidents because of the increased
and indirect cost is $8.5 billion due to its high prevalence, average population age and improved quality of life.9 A
chronic characteristics and range of therapeutic study showed that 24% stroke survivors feel severe and
interventions.2 Of all the strokes, 15% are haemorrhagic 33% moderate fatigue after stroke.10 Also, 40% survivors
and 85% are ischaemic.3 The incidence of stroke decreased are left with functional limitations and 15-30% become
approximately by 19% in the United Kingdom. 4 The handicapped, resulting in motor, sensory and cognitive
incidence of CVA is higher in south Asian, black, Chinese functions which are the major components of functional
and Japanese populations compared to the Caucasians.5 independence.11 Among physical function, gait is mostly
affected by stroke, walking speed and duration go shorter,
1,2,4Department of Physiotherapy, Paraplegic Center, Peshawar, Pakistan; 3Northwest affecting activities of daily living (ADL), leaving stroke
Institute of Health Sciences, Peshawar, Pakistan; 5Institute of Physical Medicine and patients unable to perform simultaneous tasks. 12
Rehabilitation, Khyber Medical University, Peshawar Physical therapy treatment helps in improving function
Correspondence: Aatik Arsh. e-mail: [email protected]

J Pak Med Assoc

Comparison of dual task specific training and conventional physical therapy......
8
of the affected upper and lower limbs in stroke patients.13 as Group A and the other half as Group B. These labelled
There are different physiotherapy treatment techniques papers, folded in such a manner that the labelling was
available for the rehabilitation of stroke patients, but high- not visible, were placed in a container, and the patients
quality randomized controlled trials (RCTs)have supported who fulfilled the eligibility criteria and consented to
the effectiveness of dual task training (DTT) in the participate were requested to pick one envelope for
rehabilitation of stroke patients.14 This technique involves assigning them to either of the two groups.
performing a task while doing another task, or, more Baseline readings were taken for time up and go (TUG)
simply, executing two tasks at the same time. It consists test and 10-meter walk test (10MWT).Step length, stride
of a basic motor task and an additional motor task which length, cycle time and cadence were also calculated before
is examined by changes in gait performance.14 A study and after the treatment.
conducted by Salbach et al. concluded that walking Group A, the experimental group, was exposed to DTT
distance and gait speed of stroke patients increased after for 40 minutes 4 times per week for 4 weeks. Activities
performing DTT.15 Another study revealed significant included slowly walking backward, sideways, and forward
improvement in walking abilities after 4 weeks of DTT in on a smooth surface while holding a 100g sandbag, and
stroke patients.16 A study by Kim H. et al. concluded that picking up plastic cups that lay in front of the feet while
DTT is effective in improving walking ability of stroke rising from a chair.
patients.17 Conventional physiotherapy (CPT), including
CGroup B, the control group, was exposed to CPTfor 40
mat activities, stretching and strengthening exercises,
minutes4 times per week for 4 weeks. Activities included
gait training and balance training, is also reported to be
stretching and strengthening exercises and gait training.
effective treatment for the rehabilitation of stork
Data was analysed using SPSS23.Dependent variables
patients.11,13
were cadence, step length, stride length, gait cycle, TUG
There is a need to find the comparative effect of the two test, and 10MWT.DTT and CPT were independent variables.
treatment techniques for subjects with chronic stroke. For comparison of demographic information and inter-
The current study was planned to compare the group values, independent sample t-test was used. Paired
effectiveness of DTT and CPT in ambulation of patients sample t-test was used to analyse the pre- and post-
with chronic stroke. intervention scores of the dependent variables within the
g ro u p s. P <0 .0 5 w a s c o n s i de re d s i gn if ic a n t .
Patients and Methods
The RCT was conducted at the Habib Physiotherapy Results
Complex, Peshawar, Pakistan, from January to August Of the 64 patients, there were 32(50%) in each of the two
2017. After approval from the ethics committee of Khyber groups that both had 17(53%) males and 15(47%) females.
Medical University, Peshawar, the sample size was Mean age in Group A was 58.28 ± 7.13 years, while in
calculated using online calculator18 to achieve 80% power Group B it was 58.87 ± 6.13 years (p>0.05 each)(Table 1).
with alpha value of 95% representing an equal exposed- Mean pre-treatment step length of group A and group B
to-unexposed population ratio. was 48.46±3.66cmand 47.53±54.8cm respectively
Using consecutive sample technique, male and female (p=0.370), while stride length of Group A and Group B
hemiplegic stroke patients aged 40-65 years who were was 97±7.28cm and 95.35±9.26cm respectively (p=0.430)
medically stable and had completed their initial medical (Table 2).
treatment were included. Stroke patients with medical or
physical complications, such as pressure ulcers or Table-1: Comparison of the demographic data of Group A and Group B.
contractures etc., were excluded. Also excluded were Variable Group A(n= 32) Group B(n= 32) p-value
those who were unable to follow commands and Age 58.28 ± 7.131 58.87 ± 6.131 0.722
instructions and those having visual deficit, aphasia, Gender
transient ischaemic attack (TIA) or having gait problem Male 17 (53.12%) 17 (53.12%) 1.000
due to lower limb pathologies such as fracture etc. Female 15 (46.87%) 15 (46.87%)
Hemiplegic side
Envelopes containing information sheets and data Left 18 (48.64%) 19 (51.35%)
collection tools were equally numbered with half labelled Right 14 (51.85%) 13 (48.14%)

Vol. 70, No. 1, January 2020

 M. Iqbal, A. Arsh, S.M. Hammad, et al.
9

Table-2: Comparison of the gait parameter scores of Group A and Group B patients for all gait parameters between the groups except
before treatment. for TUG test. In the current study, there was significant
Variable Group A(n= 32) Group B(n= 32) p-value improvement for the same variable. This could be due to
Pre-Step Length (cm) 48.46 ±3.66 47.53±4.58 0.37 the treatment duration where the patients performed the
Pre-Stride Length (cm) 97±7.28 95.35±9.26 0.43 training for 3 times a week in the experimental group, but
Pre-10Meterwalk test(cm/sec) 84.28±10.89 82.62±12.81 0.58
in our study the patients performed the training for 4
Pre-TUG(sec) 24.90±2.305 26.37±1.87 0.429
Pre-cycle time(sec) 1.21±0.087 1.14±0.071 0.401 times a week.22
Pre-cadence(steps/min) 93.40±3.54 95.93±3.66 0.135 A study with 20 stroke patients concluded that after
TUG: Time Up and Go Test. treatment of 4 weeks of 3 times a week, patients in the
Table-3: Comparison of the gait parameter scores of Group A and Group B experimental group improved in terms of their TUG test.23
after treatment. This is similar to our findings.
Variable Group A(n= 32) Group B(n= 32) p-value
A quasi-experimental study on the effects of DTT on gait
Post-Step Length (cm) 55.15±9.67 49.00±3.81 0.001
introduced activities for a period of 40 minutes 3 times a
Post-Stride Length (cm) 107.16±8.34 98.21±7.46 0.010
Post-10MWT (cm/sec) 101.22 ± 8.72 80.34±9.41 0.001 week for 4 weeks and reported significant improvement
Post-TUG (sec) 10.81±2.37 19.18±2.96 0.001 in gait parameters of cadence while there was no statistical
Post-Cycle Time (sec) 1.02±0.038 1.11±0.068 0.001 significant improvement in terms of step length and stride
Post-Cadence (steps/min) 103.44±4.07 98.59±3.92 0.000 length.24 This may be due to the small sample size and
Independent sample T test was applied, p-value <0.05 was taken as significant. possibly because of treatment timing. In the current study
TUG: Time Up and Go Test.
the patients were doing exercise 4 times a week for 4
Mean post-intervention step length of Group A was
weeks. Only right hemiplegic patients were recruited for
55.15±9.67 cm and for group B it was 49±3.18 cm
the study24 compared to the present study as there were
(p=0.001). Mean post-intervention stride length of Group
both right and left hemiplegic patients.
A was 107.16±8.34 cm and for group B it was 98.21±7.46
cm (p0.010)(Table 3). Another study reported results similar to those of the
current study. There was a significant improvement in the
Discussion speed of Motor Dual Task group. Inter-group analysis
Results showed that under DTT, the gait speed was showed significant improvement in step length, stride
significantly improved in the current study which is length and cadence in the experimental group25 which
supported by a study on chronic stroke patients where is similar to the findings of the present study.
the objective was to improve walking ability by DTT. There was an increase of gait speed from 52 cm/s to 69
Literature suggests patients are able to safely and cm/s after 4 weeks of training in a study conducted on
effectively ambulate in the community.19 It has been stroke patients where the change in speed was similar to
reported to function as a perambulator in most social and the present study; 17 cm/s.26 TUG test was significantly
environmental contexts a walking speed of 110 to 150 improved in the experimental group of an RCT,27 and the
cms per second is considered to be enough.20 Dean et al. results match our findings
reported a gain of 12.6 cm/s in the gait of stroke survivors Large clinical trials and multicentre studies need to be
after treatment in the experimental group, while in our conducted in order to determine effectiveness of DTT in
study the gain in speed was 16 cm/s in Group A and was comparison with other treatment options available for
significantly superior.20 The mean age of patients was the rehabilitation of stroke patients.
58.57±6.604 in the present study which is similar to those
In terms of limitations, certain confounding variables,
reported in earlier studies.21
such as psychological status, use of medications,
In the current study there was a gain in walking speed
nutritional status and family support etc., may have
after treatment, as has been reported in studies.15 The
affected the results of the current study, but it was beyond
effects of DTT in improving walking ability of stroke
the scope of the work to control these confounding
patients reported in a controlled trial17 are also similar to
variables.
our findings.
A study showed there was a significant difference in stroke

J Pak Med Assoc

Comparison of dual task specific training and conventional physical therapy......
10

Conclusion 11. Teasell R. Stroke recovery and rehabilitation. Stroke 2003;34:365-6.

12. Bloem BR, Bhatia KP. In: Bronstein AM, Brandt T, Woollacott MH, Nutt
CPT and DTT effectively improved gait ability of chronic JG, eds. Gait and balance in basal ganglia disorders: Clinical Disorders
stroke patients, but patients who received DTT showed of Balance, Posture and Gait. 2nd ed. London, England: Hodder
Headline Group, 2004.
significant improvement in all spatial and temporal gait
13. Langhammer B, Stanghelle JK. Bobath or motor relearning
variables compared to CPT. programme? A comparison of two different approaches of
physiotherapy in stroke rehabilitation: a randomized controlled study.
Limitations: The RCT was not registered with any Clin Rehabil 2000;14:361-9.
registration authority and, therefore, does not have a trial 14. Pellecchia GL, Shockley K, Turvey MT. Concurrent cognitive task
number. modulates coordination dynamics. Cogn Sci 2005;29:531-57.
15. Salbach N, Mayo N, Wood-Dauphinee S, Hanley J, Richards C, Cote
R. A task-orientated intervention enhances walking distance and
Disclaimer: The text is part of an MS (Neuro-Physical speed in the first year post stroke: a randomized controlled trial. Clin
Rehabil 2004;18:509-19.
Therapy) thesis submitted to Khyber Medical University.
16. Cho HY, Kim JS, Lee GC. Effects of motor imagery training on balance
Conflict of Interest: None. and gait abilities in post-stroke patients: a randomized controlled
Source of Funding: None. trial. Clin Rehabil 2013;27:675-80.
17. Kim BH, Lee SM, Seo K. The effects of dual-motor task training on the
gait ability of chronic stroke patients. J Phys Ther Sci 2013;25:317-
References 20.
1. Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, 18. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic
et al. Left atrial appendage closure with the Watchman device in Statistics for Public Health, Version 3.01. [Online] 2013 [Cited 2017
patients with a contraindication for oral anticoagulation: the ASAP January 03]. Available from URL:
study (ASA Plavix Feasibility Study With Watchman Left Atrial htt p s: // w ww. op en ep i. co m/ Samp le Si ze/ S SCo ho r t .ht m
Appendage Closure Technology). J Am Coll Cardiol 2013;61:2551-6. 19. Yang YR, Wang RY, Chen YC, Kao MJ. Dual-task exercise improves
2. Di Carlo A. Human and economic burden of stroke. Age Ageing walking ability in chronic stroke: a randomized controlled trial. Arch
2009;38:4-5. Phys Med Rehabil 2007;88:1236-40.
3. Luengo-Fernandez R, Gray AM, Bull L, Welch S, Cuthbertson F, Rothwell 20. Dean CM, Richards CL, Malouin F. Task-related circuit training improves
PM. Quality of life after TIA and stroke: ten-year results of the Oxford performance of locomotor tasks in chronic stroke: a randomized,
Vascular Study. Neurology 2013;81:1588-95. controlled pilot trial. Arch Phys Med Rehabil 2000;81:409-17.
4. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, 21. Shumway-Cook A, Woollacott MH. Motor control: translating research
Bennett DA, et al. Global and regional burden of stroke during 1990- into clinical practice. 3rd ed. Philadelphia, United States: Lippincott
2010: findings from the Global Burden of Disease Study 2010. Lancet Williams & Wilkins, 2007.
2014;383:245-54. 22. Kim BH, Lee SM, Bae YH, Yu JH, Kim TH. The effect of a task-oriented
5. Mackay J, Mensah GA, Mendis S, Greenlund K. The atlas of heart training on trunk control ability, balance and gait of stroke patients.
disease and stroke. Geneva, Switzerland: WHO Press, 2004. J Phys Ther Sci 2012;24:519-22.
6. Leeder S, Raymond S, Greenberg H, Liu H, Esson K. A race against 23. Kim GY, Han MR, Lee HG. Effect of dual-task rehabilitative training
time: the challenge of cardiovascular disease in developing on cognitive and motor function of stroke patients. J Phys Ther Sci
economies. New York, USA: Columbia University, 2004. 2014;26:1-6.
7. Seshadri S, Beiser A, Kelly-Hayes M, Kase CS, Au R, Kannel WB, et al. 24. Kaur J, Kumar A. Effect of task-specific training on gait parameters
The lifetime risk of stroke: estimates from the Framingham Study. in hemiparet ic stroke patients. I JPMR 2009;20:23-6.
Stroke 2006;37:345-50. 25. Shim S, Yu J, Jung J, Kang H, Cho K. Effects of motor dual task training
8. Mohan KM, Wolfe CD, Rudd AG, Heuschmann PU, Kolominsky-Rabas on spatio-temporal gait parameters of post-stroke patients. J Phys
PL, Grieve AP. Risk and cumulative risk of stroke recurrence: a Ther Sci 2012;24:845-8.
systematic review and meta-analysis. Stroke 2011;42:1489-94. 26. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL, Lew HL. Stepping
9. Nissen AI. Improving health care for stroke patients. Reorganizing a over obstacles to improve walking in individuals with poststroke
stroke unit applying Lean methodology: UiT Norges arktiske hemiplegia. J Rehabil Res Dev 2004;41:283-92.
universitet, 2014. 27. Silsupadol P, Shumway-Cook A, Lugade V, van Donkelaar P, Chou L-
10. Lerdal A, Bakken LN, Rasmussen EF, Beiermann C, Ryen S, Pynten S, S, Mayr U, et al. Effects of single-task versus dual-task training on
et al. Physical impairment, depressive symptoms and pre-stroke balance performance in older adults: a double-blind, randomized
fatigue are related to fatigue in the acute phase after stroke. Disabil controlled trial. Arch Phys Med Rehabil 2009;90:381-7.
Rehabil 2011;33:334-42.

Vol. 70, No. 1, January 2020