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.

1. ROLE OF DUAL TASK TRAINING IN
PATIENTS WITH PARKINSON’S
DISEASE.
PRESENTED BY- ABDUL BASIT
NEUROLOGICAL PHYSIOTHERAPY
abdulbasit0876@gmail.com

2. • 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.

3. • 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.

4. • 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).

5. • 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

6. • 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.

7. • 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 .

8. • 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.

9. • 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.

10. • 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.

11. • 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

12. • 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.

13. • 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.

14. • 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

15. • 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.

16. • 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.

17. • 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

18. • 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.

19. • 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

20. • 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.

21. • 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.

22. • 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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27. THANK YOU