stigger@ufcspa.edu.br

valeskamgm@gmail.com

Melina Barbosa Oviedo+

melina29_08@hotmail.com

adrianatl@ufcspa.edu.br

*Graduado em Fisioterapia pela Centro Universitário Metodista (IPA)

Mestre em Neurociências pela Universidade Federal do Rio Grande do Sul (UFRGS)

Doutor em Neurociências pela UFRGS

Professor Adjunto do Departamento de Fisioterapia

da Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA)

**Graduada em Fisioterapia pela UFCSPA

Especialista em Urgência e Emergência pelo Programa

de Residência Integrada Multiprofissional

em Urgência e Emergência (PRIMURGE)

do Hospital de Pronto Socorro de Porto Alegre

em parceria com o Instituto Metodista IPA.

Pós-graduada em Fisioterapia Intensiva pela Faculdade Inspirar

+Graduada em Fisioterapia pela UFCSPA

++Graduada em Fisioterapia pela Centro Universitário Metodista (IPA)

Mestre em Ciências do Movimento Humano pela UFRGS

Doutora em Ciências do Movimento Humano pela UFRGS

Professora Associada do Departamento de Fisioterapia da UFCSPA

(Brasil)

Reception: 04/19/2023 - Acceptance: 07/09/2023

1st Review: 06/28/2023 - 2nd Review: 07/06/2023

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Suggested reference: Stigger, F. de S., Minuscolli, V. de M.G., Oviedo, M.B., e Lemos, A.T. de (2023). Dual-Task Training Effects on Mobility of Older Adults Residents of Porto Alegre: Pilot Study. Lecturas: Educación Física y Deportes, 28(303), 106-117. https://doi.org/10.46642/efd.v28i303.3969

 

Abstract

    Introduction: Balance deficit during gait is a factor that affects older people’s mobility. It’s related to an increased risk of falls, hospitalization, and mortality. Regular physical activity is an easy and low-cost strategy to improve older adults’s functional mobility. Dual-task training is also suggested to improve balance and has been highlighted in the new World Guidelines for Falls Prevention and Management for Older Adults. Objective: This study aimed to evaluate the effects of dual-task training on functional mobility of community-dwelling older adults. Methodology: Volunteers over 60 years old were submitted to a 24-weeks exercise routine associated with dual-task challenges. On the first 12 weeks of muscular training, based on The High Intensity Functional Exercise (HIFE) Program was applied. On the following 12 weeks, cognitive challenges and dual-task exercises were added to the exercise protocol. Functional mobility was evaluated by different gait strategies (Figure 8 Walking Test, Tandem Gait Test, 10 Meter Walk Test), in admission, after 12 weeks, and at the end of 24 weeks intervention protocol. Results: Seven participants achieved the reestablished protocol length. The mean values showed that the time of execution has diminished in Tandem Gait Test and Figure 8 Walking Test, when comparing the first and the last evaluations. Conclusion: The results of the study indicate that possible dual-task exercise is an effective way to improve older adults’s gait.

    Keywords: Postural balance. Motor activity. Cognitive aging. Exercise therapy. Gait.

 

Resumo

    Introdução: O déficit de equilíbrio durante a marcha é um fator que afeta a mobilidade de idosos. Está relacionado a um aumento do risco de quedas, hospitalização e mortalidade. A atividade física regular é uma estratégia fácil e de baixo custo para melhorar a mobilidade funcional dos idosos. O treinamento de dupla-tarefa também é sugerido para melhorar o equilíbrio e tem sido destacado nas novas Diretrizes Mundiais para Prevenção e Manejo de Quedas em Idosos. Objetivo: Este estudo teve como objetivo avaliar os efeitos do treinamento de dupla-tarefa na mobilidade funcional de idosos da comunidade. Metodologia: Voluntários com mais de 60 anos foram participaram de uma rotina de exercícios de 24 semanas associada a desafios de dupla-tarefa. Nas primeiras, 12 semanas de treinamento muscular, baseado no Programa de Exercício Funcional de Alta Intensidade (HIFE), foi aplicado. Nas 12 semanas seguintes, desafios cognitivos e exercícios de dupla-tarefa foram adicionados ao protocolo de exercícios. A mobilidade funcional foi avaliada por diferentes estratégias de marcha (Figure 8 Walking Test, Teste de Marcha em Tandem, Teste de Caminhada de 10 Metros), na admissão, após 12 semanas e ao final do protocolo de intervenção de 24 semanas. Resultados: Sete participantes finalizaram o protocolo pré-estabelecido. Os valores médios mostraram que o tempo de execução diminuiu no Teste de Marcha em Tandem e no Figure 8 Walking Test, ao comparar as primeiras e últimas avaliações. Conclusão: Os resultados do estudo indicam que possivelmente o exercício de dupla-tarefa é uma maneira eficaz de melhorar a marcha de idosos.

    Unitermos: Equilíbrio postural. Atividade motora. Envelhecimento cognitivo. Terapia por exercício. Marcha.

 

Resumen

    Introducción: El déficit de equilibrio durante la marcha es un factor que afecta la movilidad de adultos mayores. Se relaciona con mayor riesgo de caídas, hospitalización y mortalidad. La actividad física regular es una estrategia fácil y de bajo costo para mejorar la movilidad funcional de personas mayores. También se sugiere entrenamiento de doble tarea para mejorar el equilibrio y ha sido recomendado en las nuevas Directrices Mundiales para la Prevención y el Tratamiento de Caídas en Adultos Mayores. Objetivo: Este estudio tuvo como objetivo evaluar los efectos del entrenamiento de doble tarea sobre la movilidad funcional de personas mayores. Metodología: Voluntarios mayores de 60 años participaron en una rutina de ejercicios de 24 semanas asociada a retos de doble tarea. En la primera se aplicaron 12 semanas de entrenamiento muscular, basado en el Programa de Ejercicio Funcional de Alta Intensidad. Durante las siguientes 12 semanas, se agregaron desafíos cognitivos y ejercicios de doble tarea al protocolo. La movilidad funcional se evaluó mediante diferentes estrategias de marcha (Figure 8 Walking Test, Tandem Walking Test, 10-meter Walk Test), al inicio, a las 12 semanas y al final del protocolo de la intervención. Resultados: Siete participantes completaron el protocolo preestablecido. Los valores medios mostraron que el tiempo de ejecución disminuyó en el Tandem Walking Test y en el Figure 8 Walking Test, al comparar las evaluaciones. Conclusión: Los resultados del estudio indican que posiblemente el ejercicio de doble tarea sea una forma eficaz para mejorar la marcha de personas mayores.

    Palabras clave: Equilibrio postural. Actividad motriz. Envejecimiento cognitivo. Terapia por ejercicios. Marcha.

 

Lecturas: Educación Física y Deportes, Vol. 28, Núm. 303, Ago. (2023)

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Introduction 

 

    Balance impairments during gait is a very prevalent characteristic between older adults and affects directly functional mobility and quality of life (LIFE Study Investigators, 2006). It’s related to an imminent risk of falls (Cleary, & Skornyakov, 2017). Falls are responsible for injuries that can be debilitating or even fatal in individuals older than 65 years old, being one of the most frequent causes of hospitalization in emergency centers. (Bergen et al., 2016)

 

    Injuries caused by a physical trauma increase chances of developing frailty syndrome in older people, which is a condition characterized by an extreme body vulnerability after a stressor event, such as a fall. It occurs when the body cannot recover from this event, never going back to its original state of health. It compromises the person’s mobility, causing permanent dependency. It’s a dynamic process, leading to successive hospitalizations, and even death. (Clegg et al., 2013)

 

    It’s well known that regular physical activities practice contributes to improve muscular performance (LIFE Study Investigators, 2006), being an easy and low-cost strategy to prevent health risk factors, the disabilities that come with age and the risk of falls (Sousa et al. 2017). In fact, effective fall prevention programs should include exercises that support daily tasks considering its complexities (Montero-Odasso et al., 2022). In this context, motor exercise training in addition to secondary cognitive tasks can benefit gait performance and prevent falls in healthy older adults (Nascimento, 2022; Montero-Odasso et al., 2022). This type of exercise requires the brain to divide its attention between the movement execution, that the physical exercise demands, and the imposed cognitive task (Plummer at al., 2015). Based on the cognitive-motor interference paradigm, dual-task training has demonstrated evidence to improve functional performance in healthy older adults and older adults with cognitive impairments (Gallou-Guyot et al., 2020; Nogueira et al., 2023). Thus, the objective of this study is to evaluate the effects of dual-task training on functional mobility of community-dwelling older adults.

 

Methods 

 

    The purpose and procedures of this study were performed according to the Declaration of Helsinki and approved by the Ethical Committees in Research of both the Federal University of Health Sciences of Porto Alegre and the Municipal Health Secretariat of Porto Alegre, under endorsement numbers 3.232.848 and 3.324.030, respectively. Participants were recruited through their referential healthcare units and advertising posters. Prior to the tests, all volunteers were asked about their availability to attend the intervention program, twice a week, during the protocol period. Additionally, all participants fully informed of the aims and procedures of the study and gave verbal and written informed content to participate in the study.

 

    Participants were included in this study if: (1) 60 years old, or more; (2) lived in the North region of the city of Porto Alegre/RS - Brazil; (3) available to participate in the scheduled days and time; (4) scored at least 24 points in the Mini-Mental State Examination (MMSE) (17 points are accepted, in case of having participant had less than 4 years of scholarity). Participants were excluded if had physical limitations that prevent the execution of the proposed exercises; non-controlled chronic diseases; incapacitating pain; abandon the exercise program or had attendance rate inferior of 75%.

 

    Initially, participants answered an anamnesis composed by identification data (name, date of birth, place of birth, provenance, address, phone number, scholarity, current occupation, weight, height), previous diseases (high blood pressure, diabetes, heart failure, respiratory failure, depression, among others), medication, life habits (smoking, alcoholism, daily activities), and in case of pain, its classification through Visual Analog Scale - VAS.

 

    Functional mobility was assessed by three walking tasks: 10-meter Walk Test (10MWT), Figure-8 Walk Test (F8WT) and Tandem Gait Test (TGT) in single and dual-tasking (TGT-DT). Those testes were validated and consisted in walking in different strategies. 10WT has the objective of evaluating mobility, through speed of gait. Individuals were instructed to walk comfortably, but as fast as they can, on a 14-meters path (Peters et al., 2013; Esain et al., 2021). F8WT is a test designed to simulate straight and curved paths, representing daily walking, broadly used to evaluate gait in older adults with walking difficulties (Pessoa et al., 2020). During this protocol, the time, in seconds, was considered (Hess et al., 2010). Tandem Gait Test is an easy-implemented and objective test, that evaluates the dynamic postural control (Chantanachai et al., 2014). Tandem Gait Test were performed associated with a secondary verbal fluency test (volunteers were asked to speak the maximum number of animals they could). To analyze dual task interference, relative dual task effects of Tandem Gait Test were calculated with the following formula: DTE (%) = ± [(DT - ST) / ST] x 100, where DTE means dual task effect, DT means dual task, and ST means simple task. (Ramos et al., 2012; Plummer et al., 2015)

 

    All functional mobility tasks were performed and at three different moments: (1) before the begin of intervention protocol, (2) after 12-weeks HIFE protocol, in the middle of the schedule and (3) following the 24-weeks interventional procedure. Individual results in all three evaluations were compared.

 

    The training protocol required attendance 2 times per week at the “Centro Humanístico Vida” at Porto Alegre - Rio Grande do Sul. Each session lasted for one hour and comprised a warm-up period of 5-10 min at the start, a main Hight Intensity Functional Exercise (HIFE) period for at least 40 minutes and cool-down period of similar duration at the end of each session.

 

    During the first 12 weeks, training protocol were based only on HIFE aimed to improve participant’s lower limbs strength, balance and mobility. Original HIFE protocol is composed by 39 exercises, divided into 5 categories (Littbrand et al., 2014). On the following 12 weeks, motor or cognitive challenges were added to HIFE training. For this, secondary motor and/or cognitive tasks were applied during the execution of motor task. Those tasks include such as describing the right color in which the word is written, saying out loud the days of the week or months of the year backwards, memorizing a sequence of words, describing in detail all the activities that were made during the day since the moment they woke up until that moment, transferring coins from one pocket to another, making simple math calculation. Warm-up and cool-down activities in the beginning and at the end of each day were similar in all the intervention span.

 

    For sample characterization, descriptive statistics was used through mean and standard deviation for continuous variables, and for categorical variables, the frequency of occurrence. To compare the results of post 1 and post 2-test functionality tests, Wilcoxon test was used. For all analyzes, the program SPSS version 18.0 was used and a significance level of 5% was adopted.

 

Results 

 

    A total of 7 older adults attended the pre-established protocol. The fluxogram describes sample composition (Figure 1).

 

Source: Self made

 

    Characteristics of all participants are summarized in Table 1.

 

	Absolute frecuency	Percentage frequency
Gender
Male	3	42,9%
Female	4	57,1%
Occupation
Retired	5	71,4%
Homeworker	2	28,6%
Marital state
Single	2	28,6%
Married	5	71,4%
Scholarity
1° degree	5	71,4%
2° degree	2	28,6%
Diabetes
Yes	2	28,6%
No	5	71,4%
Respiratory diseases
Yes	1	14,3%
No	6	85,7%
Cardiopaties
Yes	1	14,3%
No	6	85,7%
Urinary incontinence
Yes	1	14,3%
No	6	85,7%
Falls
Yes	2	28,6%
No	5	71,4%
Pain
Yes	2	28,6%
No	5	71,4%

Source: Self made

 

    Mean values of F8W, 10MWT, and the TGT in pre and post assessments are presented on Figure 2. A significant statistical difference between the first and the third evaluations (p=0,018), as well as from the second to the third evaluations (p=0,043) on F8W test was observed. There were no significative differences on the 10MT between all the accomplished evaluations. Considering the TGT, there was a significant difference between the first and the third evaluations (p=0,028). Also, there were no significant statistical results in DTE during dual task assessment (Table 2).

 

Source: Self made

 

	Baseline	12 Weeks	24 Weeks
TGT (time/sec)	33,37±5,8	30,59±4,6	24,98±3,8
TGT-DT (time/sec)	42,92±15,4	43,61±13,3	35,41±8,7
DTE (%)	-29,32	-46,10	-40,72

Source: Self made

 

Discussion 

 

    In our knowledge, this is the first study to apply an exercise protocol based on the HIFE program associated to cognitive training through dual-task challenges, in order to evaluate its effects on functional mobility of older adults. Previous studies have found that physical training, as much as cognitive training, are both effective in improving cognition in older people, and that they are even more efficient when combined (Falbo et al., 2016). In a systematic review, Pichierri et al. (2011) considered the necessity of cognitive training to improve physical functioning. Their results demonstrated that older adults had a great impact on gait when performed with a simultaneous cognitive task. It suggests using dual-task exercises with physical and cognitive approaches, in fall prevention programs.

 

    Although previous studies have demonstrated that dual-task training is an effective and advantageous strategy that improves gait performance and cognitive abilities among healthy older individuals (Tasvuran Horata et al., 2021) or with cognitive impairment (Costa, 2022), there is still limited evidence on the efficiency of motor-cognitive dual task interventions compared to single task training (Fraser et al., 2016), and how they could improve physical function in older adults (Pichierri et al., 2011). In this study, it was found that the time to perform the proposed walking tests has diminished between the first and second evaluations, where the interventions were based only in physical performance, and reduced even more from the second to the last evaluations, when cognitive challenges were added to the interventions, in both Tandem Gait Test, and in Figure 8 Walking Test.

 

    These results are encouraging, and show that the training protocol was effective, improving the confidence of the participants in their gait through an increase of gait speed. According to Espeland et al. (2017), regular physical activities practice is able to benefit gait speed, in inactive older individuals with no chronic diseases who are physically vulnerable, meeting the results found by this research. Apóstolo et al. (2018) show the relation between physical and cognitive interventions, and an improvement of physical capacities of older individuals, which also concur to the found results.

 

    Although in our evaluations there was no significant improvement on 10 meter walking test results, they indicate a slight decrease in time of execution from the first to the second evaluations, that remained in a plateau from the second to the third evaluations, indicating also, that there was no increase of the time to execute the test. Being the less demanding of the three applied tests, because of a broader walking base in a straight path, the hypothesis is that as this is the most usual gait pattern, the participants were already confident to execute this kind of gait before the interventions. Countering this findings, Santos et al. (2017) have tested gait speed in 23 older women after a 8-week resistance training, and concluded there were improvements in the 10 Meter Walking Test results after the intervention.

 

    It is known that when cognitive tasks are performed during gait in older adults, decrements on either gait or cognition are observed (Falbo et al., 2016). In this scenario, training gait simultaneously to cognitive stimulation is fundamental in order to favor daily walking. Being the first time in which cognitive exercises were applied in this population in association to lower limb endurance, we can assume that the dual-task motor cognitive training executed on this research caused an improvement in gait of older adults. As a follow-up, it’s possible to make new evaluations to find out if the results of cognitive training remained, even after the dual-task stimulation has finished.

 

    The results of this study were promising, in spite of not having external validation due to a huge loss in the number of participants through the weeks of intervention. An alternative would be having domiciliary interventions instead of a group schedule, which could improve the adherence to the program, on the other hand, this approach would contribute to the isolation of the individuals, which could make the interventions less interesting to the participants. Further studies with more participants are recommended. Another suggestion would be having two different groups, with two different approaches (only physical exercise x motor cognitive dual-task exercises).

 

    In short, this study concludes that motor-cognitive dual-task exercises are an effective way to improve functional mobility of older adults, as shown by the reduction of the time to execute Tandem Gait Test and Figure 8 Walking Test, as the training weeks progress. A larger population would be desirable in order to achieve more significant results.

 

References 

 

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Bergen, G., Stevens, M.R., & Burns, E.R. (2016). Falls and fall injuries among adults aged ≥ 65 years — United States, 2014. Morbidity and Mortality Weekly Report (MMWR), 65(37), 993-998. https://doi.org/10.15585/mmwr.mm6537a2

 

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Lecturas: Educación Física y Deportes, Vol. 28, Núm. 303, Ago. (2023)