Restricted accessResearch articleFirst published online 2025-8
Effects of Cognitive Task Type and Complexity on Dual-Task Interference During Level-Ground Walking and Obstacle Negotiation in Individuals with Stroke
Compromised dual-task walking ability reduces functional independence in community-dwelling individuals after stroke. Objective. To examine the influence of mobility task and cognitive task type and complexity, and their interaction on dual-task level-ground walking and obstacle-crossing after stroke.
Methods
Ninety-three individuals with chronic stroke (mean [SD] age = 62.4 [6.7] years, stroke duration = 67.7 [53.5] months) participated in this observational study with repeated measures. For each dual-task testing condition, a mobility task (level-ground walking or obstacle-crossing) was performed concurrently with 1 of 5 cognitive tasks (serial-subtractions, category naming, clock test, auditory discrimination, and shopping-list recall). Each cognitive task involved low and high complexity levels, yielding 20 dual-task conditions in total. Dual-task effect (DTE = [single-task − dual-task]×100/single-task) on walking distance (mobility-DTE) and number of correct responses (cognitive-DTE) were calculated for each dual-task condition.
Results
Medium to large interaction effects were observed between cognitive task type and complexity on cognitive (F = 12.0-15.8, P < .001, ηp2 = 0.12-0.15) and mobility performance (F = 3.2-5.5, P < .05, ηp2 = 0.03-0.06) during dual-task level-ground walking and obstacle-crossing. Among the cognitive tasks, serial-subtraction had the greatest interference effect on both cognitive (Mean DTE = −9.2 to −21.5%) and mobility performance (Mean DTE = −18.7 to −19.1%). Overall, “mobility interference” (decrement in walking distance without a decrement in cognitive performance) was the most common dual-task effect pattern observed.
Conclusion
The type and complexity level of the mobility and cognitive tasks interact to influence the degree and pattern of dual-task effects, with the serial-subtraction task inducing the greatest effect. Standardized assessments involving distinct cognitive domains are necessary for profiling dual-task interference during walking among individuals with chronic stroke.
PatelPBhattT.Task matters: influence of different cognitive tasks on cognitive-motor interference during dual-task walking in chronic stroke survivors. Top Stroke Rehabil. 2014;21(4):347-357. doi:10.1310/tsr2104-347
2.
LordSEWeatherallMRochesterL.Community ambulation in older adults: which internal characteristics are important?Arch Phys Med Rehabil. 2010;91(3):378-383.
3.
ShinkaiSWatanabeSKumagaiS, et al. Walking speed as a good predictor for the onset of functional dependence in a Japanese rural community population. Age Ageing. 2000;29(5):441-446.
4.
AnderssonAGKKSeigerAAppelrosP. How to identify potential fallers in a stroke unit: validity indexes of four test methods. J Rehabil Med. 2006;38(3):186-191.
5.
TsangCSLMillerTPangMYC. Association between fall risk and assessments of single-task and dual-task walking among community-dwelling individuals with chronic stroke: a prospective cohort study. Gait Posture. 2022;93:113-118. doi:10.1016/j.gaitpost.2022.01.019
6.
TsangCSLChongDYKPangMYC. Cognitive-motor interference in walking after stroke: test-retest reliability and validity of dual-task walking assessments. Clin Rehabil. 2019;33(6):1066-1078. doi:10.1177/0269215519828146
7.
TsangCS-LWangSMillerTPangMY-C. Degree and pattern of dual-task interference during walking vary with component tasks in people after stroke: a systematic review. J Physiother. 2022;68(1):26-36. doi:10.1016/j.jphys.2021.12.009
8.
PashlerH.Dual-task interference in simple tasks: data and theory. Psychol Bull. 1994;116(2):220-244. doi:10.1037/0033-2909.116.2.220
9.
PlummerPEskesGWallaceS, et al. Cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research. Arch Phys Med Rehabil. 2013;94(12):2565-2574.e6. doi:10.1016/j.apmr.2013.08.002
10.
Al-YahyaEJohansen-BergHKischkaUZareiMCockburnJDawesH.Prefrontal cortex activation while walking under dual-task conditions in stroke: a multimodal imaging study. Neurorehabil Neural Repair. 2016;30(6):591-599. doi:10.1177/1545968315613864
HackneyMEHallCDEchtKVWolfSL.Application of adapted tango as therapeutic intervention for patients with chronic stroke. J Geriatr Phys Ther.2012;35(4):206-217. doi:10.1519/JPT.0b013e31823ae6ea
13.
ManafHJustineMGohH-T.Effects of attentional loadings on gait performance before turning in stroke survivors. PM & R. 2015;7(11):1159-1166. doi:10.1016/j.pmrj.2015.05.007
14.
YangLHeCPangMY.Reliability and validity of dual-task mobility assessments in people with chronic stroke. PLoS ONE. 2016;11(1):e0147833. doi:10.1371/journal.pone.0147833
15.
Plummer-D’AmatoPAltmannLJPSaracinoDFoxEBehrmanALMarsiskeM.Interactions between cognitive tasks and gait after stroke: a dual task study. Gait Posture. 2008;27(4):683-688. doi:10.1016/j.gaitpost.2007.09.001
16.
HyndmanDAshburnAYardleyLStackE.Interference between balance, gait and cognitive task performance among people with stroke living in the community. Disabil Rehabil. 2006;28(13-14):849-856. doi:10.1080/09638280500534994
17.
CockburnJHaggardPCockJFordhamC.Changing patterns of cognitive-motor interference (CMI) over time during recovery from stroke. Clin Rehabil. 2003;17(2):167-173. doi:10.1191/0269215503cr597oa
18.
PohlPSKemperSSiengsukonCFBoydLVidoniEHermanRE.Older adults with and without stroke reduce cadence to meet the demands of talking. J Geriatr Phys Ther. 2011;34(1):35-40. doi:10.1519/JPT.0b013e31820aa8e6
19.
ChaikeereeNChinsongkramBSaengsirisuwanVBoonsinsukhR.Effect of cognitive task on components of 7 metertimed up-and-go test in persons with stroke. Scienceasia. 2018;44:247.
20.
TisserandRArmandSAllaliGSchniderABaillieulS.Cognitive-motor dual-task interference modulates mediolateral dynamic stability during gait in post-stroke individuals. Hum Move Sci. 2018;58:175-184. doi:10.1016/j.humov.2018.01.012
21.
FeldJAZukowskiLAHowardAG, et al. Relationship between dual-task gait speed and walking activity poststroke. Stroke. 2018;49(5):1296-1298. doi:doi:10.1161/STROKEAHA.117.019694
22.
HermandETapieBDupuyO, et al. Prefrontal cortex activation during dual task with increasing cognitive load in subacute stroke patients: a pilot study. Front Aging Neurosci. 2019;11:160. doi:10.3389/fnagi.2019.00160
23.
Deblock-BellamyALamontagneABlanchetteAK.Cognitive-locomotor dual-task interference in stroke survivors and the influence of the tasks: a systematic review. Front Neurol. 2020;11:882. doi:10.3389/fneur.2020.00882
24.
BleAVolpatoSZulianiG, et al. Executive function correlates with walking speed in older persons: the InCHIANTI study. J Am Geriatr Soc. 2005;53(3):410-415. doi:10.1111/j.1532-5415.2005.53157.x
25.
World Medical A. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA. 2013;310(20):2191-2194. doi:10.1001/jama.2013.281053
26.
WongAXiongYYKwanPW, et al. The validity, reliability and clinical utility of the Hong Kong Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease. Dement Geriatr Cogn Disord. 2009;28(1):81-87.
27.
BanksJLMarottaCA.Outcomes validity and reliability of the modified rankin scale: implications for stroke clinical trials. Stroke. 2007;38(3):1091-1096. doi:10.1161/01.STR.0000258355.23810.c6
28.
FaulFErdfelderELangA-GBuchnerA.G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175-191. doi:10.3758/BF03193146
29.
YangLLamFMHuangMHeCPangMY.Dual-task mobility among individuals with chronic stroke: changes in cognitive-motor interference patterns and relationship to difficulty level of mobility and cognitive tasks. Eur J Phys Rehabil Med. 2018;54(4):526-535. doi:10.23736/s1973-9087.17.04773-6
30.
ChauJMartinCRThompsonDRChangAMWooJ.Factor structure of the Chinese version of the Geriatric Depression Scale. Psychol Health Med. 2006;11(1):48-59. doi:10.1080/13548500500093688
31.
MakMKLauALLawFSCheungCCWongIS. Validation of the Chinese translated activities-specific balance confidence scale. Arch Phys Med Rehabil. 2007;88(4):496-503. doi:10.1016/j.apmr.2007.01.018
32.
FlansbjerU-BHolmbäckAMDownhamDPattenCLexellJ.Reliability of gait performance tests in men and women with hemiparesis after stroke. J Rehabil Med. 2005;37(2):75-82. doi:10.1080/16501970410017215
33.
TsangCSLLiaoL-RChungRCKPangMYC. Psychometric properties of the mini-balance evaluation systems test (Mini-BESTest) in community-dwelling individuals with chronic stroke. Physical Therapy. 2013;93(8):1102-1115. doi:10.2522/ptj.20120454
34.
Fugl-MeyerARJääsköLLeymanIOlssonSSteglindS.A method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31.
35.
MorganALBrandtJF.An auditory Stroop effect for pitch, loudness, and time. Brain Lang. 1989;36(4):592-603.
36.
GomezRGWhiteDA.Using verbal fluency to detect very mild dementia of the Alzheimer type. Arch Clin Neuropsychol. 2006;21(8):771-775. doi:10.1016/j.acn.2006.06.012
37.
WilliamsMALaMarcheJAAlexanderRWStanfordLDFielsteinEMBollTJ.Serial 7s and Alphabet Backwards as brief measures of information processing speed. Arch Clin Neuropsychol. 1996;11(8):651-659.
38.
HaggardPCockburnJCockJFordhamCWadeD.Interference between gait and cognitive tasks in a rehabilitating neurological population. J Neurol Neurosurg Psychiatry. 2000;69(4):479-486. doi:10.1136/jnnp.69.4.479
39.
Al-YahyaEDawesHSmithLDennisAHowellsKCockburnJ.Cognitive motor interference while walking: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2011;35(3):715-728.
40.
PlummerPZukowskiLAGiulianiCHallAMZurakowskiD.Effects of physical exercise interventions on gait-related dual-task interference in older adults: a systematic review and meta-analysis. meta-analysis review. Gerontology. 2015;62(1):94-117.
41.
RichardsonJTE. Eta squared and partial eta squared as measures of effect size in educational research. Educ Res Rev. 2011;6(2):135-147. doi:10.1016/j.edurev.2010.12.001
42.
NormanGRSloanJAWyrwichKW.Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5):582-592.
43.
International Labour Office. International Standard Classification of Occupations 2008 (ISCO-08): Structure, group definitions and correspondence tables. International Labour Office; 2012.
44.
WuCYHungSJLinKCChenKHChenPTsayPK.Responsiveness, minimal clinically important difference, and validity of the MoCA in stroke rehabilitation. Occup Ther Int. 2019;2019:2517658. doi:10.1155/2019/2517658
45.
BohannonRWGlenneySS.Minimal clinically important difference for change in comfortable gait speed of adults with pathology: a systematic review. J Eval Clin Pract. 2014;20(4):295-300. doi:10.1111/jep.12158
46.
LeoneCFeysPMoumdjianLD’AmicoEZappiaMPattiF.Cognitive-motor dual-task interference: a systematic review of neural correlates. Neurosci Biobehav Rev. 2017;75:348-360. doi:10.1016/j.neubiorev.2017.01.010
47.
KahnemanD.Attention and effort. Prentice-Hall; 1973.
48.
DrummondSPABrownGGStrickerJLBuxtonRBWongECGillinJC. Sleep deprivation-induced reduction in cortical functional response to serial subtraction. Neuroreport. 1999;10(18):3745-3748. doi:10.1097/00001756-199912160-00004
49.
SchaapsmeerdersPMaaijweeNAMVan DijkEJ, et al. Long-term cognitive impairment after first-ever ischemic stroke in young adults. Stroke (1970). 2013;44(6):1621-1628. doi:10.1161/STROKEAHA.111.000792
50.
HuxholdOLiS-CSchmiedekFLindenbergerU.Dual-tasking postural control: aging and the effects of cognitive demand in conjunction with focus of attention. Brain Res Bull. 2006;69(3):294-305. doi:10.1016/j.brainresbull.2006.01.002
51.
Yogev-SeligmannGRotem-GaliliYMirelmanADicksteinRGiladiNHausdorffJM.How does explicit prioritization alter walking during dual-task performance? Effects of age and sex on gait speed and variability. Phys Ther. 2010;90(2):177-186. doi:10.2522/ptj.20090043
52.
TsangCSLPangMYC.Association of subsequent falls with evidence of dual-task interference while walking in community-dwelling individuals after stroke. Clin Rehabil. 2020;34(7):971-980. doi:10.1177/0269215520923700
53.
PangMYCYangLOuyangHLamFMHHuangMJehuDA. Dual-task exercise reduces cognitive-motor interference in walking and falls after stroke. Stroke. 2018;49(12):2990-2998. doi:10.1161/STROKEAHA.118.022157
54.
PlummerPVillalobosRMVaydaMSMoserMJohnsonE.Feasibility of dual-task gait training for community-dwelling adults after stroke: a case series. Stroke Res Treat. 2014;2014:538602. doi:10.1155/2014/538602
55.
KahnemanD.Attention and effort. vol 1063. Citeseer; 1973.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
