Purpose: 
The aim of this systematic review of the literature is to investigate the application of cognitive and motor dual task paradigms in the physical therapy management of moderate to severe TBI population across the lifespan in physical therapy practice.https://jdc.jefferson.edu/dptcapstones/1001/thumbnail.jp

Bilski, Lauren

Clancy, Kathleen

Dean, Victoria

Hunter, PT, DPT, Louis N

Melfi, Danielle

Reardon, Kristin

Purpose: 
The aim of this systematic review of the literature is to investigate the application of cognitive and motor dual task paradigms in the physical therapy management of moderate to severe TBI population across the lifespan in physical therapy practice.http://jdc.jefferson.edu/dptcapstones/1001/thumbnail.jp

Name not available

Application of Dual Task Performance in Pediatrics and Adults with Traumatic Brain Injury: A Systematic Review

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Physical Therapy Capstone Posters Student Materials2-12-2016Application of Dual Task Performance in Pediatricsand Adults with Traumatic Brain Injury: ASystematic ReviewLauren BilskiDepartment of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA,lauren.bilski@jefferson.eduKathleen ClancyDepartment of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA,kathleen.clancy@jefferson.eduVictoria DeanDepartment of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA,victoria.dean@jefferson.eduDanielle MelfiDepartment of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA,danielle.melfi@jefferson.eduKristin ReardonDepartment of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA,kristin.reardon@jefferson.eduThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Physical Therapy Capstone Posters by an authorized administrator of the Jefferson Digital Commons. For more information, pleasecontact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationBilski, Lauren; Clancy, Kathleen; Dean, Victoria; Melfi, Danielle; Reardon, Kristin; and Hunter, PT, DPT, Louis N., "Application ofDual Task Performance in Pediatrics and Adults with Traumatic Brain Injury: A Systematic Review" (2016). Department of PhysicalTherapy Capstone Posters. 2.http://jdc.jefferson.edu/dptcapstones/2See next page for additional authorsFollow this and additional works at: http://jdc.jefferson.edu/dptcapstonesPart of the Physical Therapy CommonsAuthorsLauren Bilski; Kathleen Clancy; Victoria Dean; Danielle Melfi; Kristin Reardon; and Louis N. Hunter, PT,DPTThis book is available at Jefferson Digital Commons: http://jdc.jefferson.edu/dptcapstones/2In physical therapy practice, dual task training (DTT) has been utilized in patients with neurologic dysfunction, and there is consistent evidence in the literature to support the implication of such paradigms. Despite previous understanding that gait is largely an automatic skill, research has found that “gait is indeed an attention-demanding, high-level, controlled task”.1  Individuals with neurologic dysfunction have both cognitive and motor processing deficits that impact attention and functional abilities.  Dual task performance is relevant in neurologic populations due to an inverse relationship between dual task costs and automaticity of gait.1  Additionally, this association between attention and mobility is integral for appropriate navigation of complex environments encountered in daily life. Thus, the ability to divide attention and selectively orient to appropriate tasks is an important skill that precipitates everyday function.2 Dual task training is defined broadly as simultaneous performance of two concurrent tasks, this can be the combination of two motor tasks or a motor task and a cognitive task.3 Common sequelae of traumatic brain injury (TBI) include decreased sustained and divided attention, reduction in cognitive processing, impaired ability to complete motor tasks automatically, and compromised executive function.2,4,5 Survivors of moderate to severe TBI  may suffer from impaired attention and increased distractibility.2,4,6,7 TBI affects 1.7 million individuals annually, and the rate has been continually increasing over time.8  Based on these statistics, almost half a million hospital visits associated with TBI encompass children from birth through 14 years of age.8  This further magnifies the need to identify effective rehabilitation interventions for improved community re-integration.   Application of Dual Task Performance in Pediatrics and Adults with Traumatic Brain Injury: A Systematic Review  Background Methods Preliminary Search ● Databases Searched: PubMed, Scopus, Medline Ovid, Google Scholar ● Search terms: brain injury, traumatic brain injury, physical therapy, physiotherapy, rehabilitation, dual-task, divided attention, pediatric, adolescent, children, attention, cognition and balance. ● Search conducted: individually by the five primary authors ● Inclusion: participants diagnosed with a moderate to severe traumatic brain injury; incorporation of a DT intervention (pairing a cognitive task with a lower extremity functional motor task);  use of least one functional outcome measure;  written in English and published within last 10 years (since 2005).  (See exclusion criteria at each selection stage below)                                                                                      Results Discussion The application of cognitive and motor dual task paradigms in the moderate to severe traumatic brain injury population may improve functional outcomes and rehabilitation progression to everyday tasks and environments. Results of these studies demonstrated that there is a relationship between DTT and the four outcomes of mobility (gait speed, step/ stride length, balance, and foot clearance) across the lifespan but further research is required to illustrate the significance of such a relationship. There was also a correlation found between performance on the neuropsychological assessments and performance of DTT.  The majority of the studies reviewed demonstrated a decrease in gait speed with the introduction of DTT, with the exception of the case study that utilized dual task as an intervention. All other mobility outcomes identified had variable results, making it difficult to generalize to the TBI population. These variations were due to: • several discrepancies in outcome measures chosen • inconsistencies between DTT protocols  • range in time elapsed from injury to the application of the DTT Therefore, the implementation of dual task as an intervention over a period of time in the moderate to severe TBI population is recommended to further clarify the relationship between dual task and gait parameters.     Future Research Future research regarding DTT in the moderate to severe TBI population across the lifespan should focus on the following: ● Pilot studies that aim to develop recommendations for pediatric specific outcome measure, such as the TBIEDGE for adults 16  ● Outcome measures assessed in both controlled settings versus functional environments to determine when complex environments are appropriate to introduce in patients recovering from TBI ● Recommendations for the introduction of DTT along the lifespan  References Evaluation of Quality and Risk of Bias • Utilized:  Physiotherapy Evidence Database (PEDro) scale is based on the Delphi list.9 Each of the included studies was read and graded by all five authors independently. The individual scores were compared, item by item, and any inconsistencies were discussed in order to determine an overall grading based on team consensus. Purpose The aim of this systematic review of the literature is to investigate the application of cognitive and motor dual task paradigms in the physical therapy management of moderate to severe TBI population across the lifespan in physical therapy practice.  Results (cont.) IDENTIFICATION SCREENING ELIGIBILITY INCLUDED Potentially relevant articles  identified from  database searches  (n=288) Records after duplicates removed (n=189) Titles and abstracts screened (n=125) Full-text articles  assessed for eligibility (n=28+1=29) Articles included in the systematic literature review (n=6) Excluded (n=64) ● Prior to 2005 (within 10 years) Excluded (n=97) ● CP, Stroke, Concussion ● Imaging ● Animal studies ● Medical/surgical interventions ● Only upper extremity functional task Excluded (n=23) ● Abstract/Full text  in English (n=1) ● Stroke (50%) (n=1) ● Concussion (n=10) ● Older adult (n=2) ● DT solely cognitive (n=1) ● DT UE (n=2) ● DT visuospatial  (n=2) Additional articles identified through review of references of selected articles and outside sources  (n=1) The Ideal Study ● Randomized control trial with a control group and two experimental TBI groups: 17 ● Large sample size ● Homogenous injury severity found using standardized brain injury assessment tools ( GCS, Rancho Los Amigos Scale) ● Functional mobility and cognitive standardized assessment tools 16, 18   ● DTT applied as an intervention over a period of time, with a functional motor subtask  Conclusion Due to the possibility of attention and cognitive processing deficits in the TBI population, there is a necessity for physical therapists to address motor skills within functional daily scenarios. Interventions requiring dual tasking could help with  addressing these persistent attentional deficits that interfere with daily living after a TBI. However, there is insufficient quality of evidence to support and justify using DTT during physical therapy for patients with moderate to severe TBI. Further research among adults and pediatric TBI populations is warranted due to the ubiquity of dual task paradigms in everyday tasks.  Table 2. Results Articles  Study Design Results of Outcome Measures Cantin10 (2007)  Group comparison study - ↑ time for the TBI group for the Trail Making B, Stroop Color, Stroop Word, and Stroop Interference tests - ↓ scores for the TBI group on the Symbol Digit Modalities Test and the Brown-Peterson test - Significant relationship between Trail Making B results to obstacle clearance margin for: Stroop Bar with narrow obstacle for lead and trail limb **; Stroop Word with narrow obstacle trail limb **; Stroop Word with narrow obstacle lead limb *; Stroop Bar with deep obstacle for lead and trail limb*; Stroop Word with deep obstacle for lead and trail limb* Fritz11  (2013) Case study - ↑ in FIM level - ↓ error and ↓ time for completion of WWTT simple and WWTT complex in Phase B - ↓ error and ↓ time for completion of  significant value in Phase B Trail Making Test  - ↑ gait speed in Phase A with < ↑ of gait speed in Phase B (3x) - ↓ time to descend 10 stairs in Phase A reduced by 2.66 sec   - ↓ time to descend 10 stairs in Phase B reduced by 7.49 sec Katz-Leurer12  (2011) Group comparison study - ↑ mistakes in sound recognition assignment in TBI group** - ↓gait velocity with dual task conditions (both groups showed ↓, but TBI more significant)** - ↑ mean step time in dual task condition compared to baseline for both groups** - ↓ step length in the sound assignment McCulloch13 (2010) Cross- Sectional study - Correlation between DTC to BBS, FSST, and HiMAT (3 balance measures) were highest (P≤0.004) - SDMT and MARS scores were also significantly correlated to a lesser degree (p≤ 0.05) - Subjects reporting at least 1 fall in the past 6 months (n=13) ↓ BBS (P≤0.03) and ↑ time FSST (P≤0 .01) than subjects reporting no falls (n=11) - Nonfallers ↑ HiMAT compared to nonfallers (P≤0.03) Vallee14 (2006) Group comparison study - ↑ reading time for the TBI group to perform the Stroop Bar while avoiding the narrow obstacle (p=0.05), and in performing the Stroop Word task while avoiding the wide obstacle (p=0.019) - ↓ walking speed in the TBI group compared to the control for the most complex dual task (p=0.042) (wide obstacle and Stroop Word task) - ↓ crossing speeds while stepping over the wide obstacle in combination with division of attention, Stroop Bar (p=0.02) or Stroop Word (p=0.027) compared to unobstructed walking in TBI pts - ↓ lead limb stride length for the two obstacle conditions with the Stroop Bar (p=0.002) and with the Stroop Word (p=0.05 for the narrow, p=-.003 for the wide obstacles) - ↓ lead limb stride length with performance of Stroop Word > Stroop Bar during unobstructed walking - ↑ lead limb clearance margins for TBI group for all conditions (p<0.001) Zhariko15 (2011) Group comparison study - ↓ quality of cognitive subtask for the TBI group in both separate and dual task significantly worse than in the healthy controls; especially for C2 subtask and G2* - ↑ quality of C1 subtask by G1 in the dual task of M2C1 compared to the separate performance* - ↓ velocity, sig below the normative values for G1 motor subtask during M2C2* - + correlation improvement in performance of both subtasks and the degree of preservation of cognitive function, level of adaptation and degree of cognitive deficit * p<0.05, ** p<0.01 Table 1. Study Participant Demographics   Participants     Mechanism of Injury     TBI Severity     Time Since Injury   TBI participants Control participants Articles Gender Mean Age (years) Gender Mean Age (years) Cantin10 (2007) M: 8 F: 2 37 ± 13.7 M: 8 F: 2 38.4 ± 13.3 Not stated GCS 7.6 ± 2.6   5.4 ± 8.4 months Fritz11 (2013) F:1 26 N/A N/A MVA Rancho V/ evolving Rancho VI day 57 post injury 46 days 65 days when DTT began Katz-Leurer12 (2011) M:9 F:6 9. 5 ± 2.2 M:10 F:5 9.9 ± 1.3 “post-severe closed head injury”   GCS ≤ 8 at time of admission to ER   Average 3.5 years (Range 1.5-7 years) McCulloch13 (2010) M: 18 F: 6 39.4 ± 13.3 N/A N/A - MVA: 12 - Fall: 9 - Other: 3 Not stated 117.8 ± 125.2 months Vallee14 (2006) M: 8 F: 1 39.3 ± 13.0 M: 8 F: 1 39.7 ± 12.3 Not stated GCS 7.8 ± 2.6   1-28.2 months Zharikova15 (2011) Total: 14 25.7 ± 4.7 Total: 40 29.8 ± 2.47 “multiple bilateral brain injury, 5 had diffuse axonal lesion”   Group 1 (satisfactory) GCS:11.5 (9.25-12.0) Group 2 (severe) GCS: 5 (3.25-7.5) 5 3 - 6 months F-female; M-male Figure 1. Article Selection Graph 1. PEDro Scores  Each study was assessed for strength          using the PEDro Scale9: ·       A maximum score is 11 points. ·       Scores are inherently lower due to the fact  this scale is                        designed to evaluate randomized  control trials. This review                            did not consist of  any randomized control trials, but is the                        standardized scale for evaluation of physical therapy                       interventions.   Common areas of weakness ·       Subjects were not randomly allocated to groups ·       Allocations were not concealed ·       Subjects, therapists, and assessors were not  blinded ·       One key outcome measure was not obtained from more               than 85% of subjects ·       Not all subjects in which outcome  measures  were  available received  treatment or control condition as allocated.    1. Yogev-Seligmann G, Hausdorff J, Giladi N. The role of executive function and attention in gait. Movement Disorders. 2008;23(3):329-342. 2. McCulloch K. Attention and Dual-Task Conditions: Physical Therapy Implications for Individuals With Acquired Brain Injury. Journal Of Neurologic Physical Therapy. 2007;31(3):104-118. 3. Pellecchia GL. Dual-task training reduces impact of cognitive task on postural sway. Journal of Motor Behavior. 2005;37:239–246. 4. Mathias J, Wheaton P. Changes in attention and information-processing speed following severe traumatic brain injury: A meta-analytic review. Neuropsychology. 2007;21(2):212-223.  5. Azouvi P, Couillet J, Leclercq M, Martin Y, Asloun S, Rousseaux M. Divided attention and mental effort after severe traumatic brain injury. Neuropsychologia. 2004;42(9):1260-1268.  6. Couillet J, Soury S, Lebornec G, Asloun S, Joseph P, Mazaux J, Azouvi P. Rehabilitation of divided attention after severe traumatic brain injury: A randomised trial. Neuropsychological Rehabilitation. 2010;20(3):321-339. 7. Brauer S, Broome A, Stone C, Clewett S, Herzig P. Simplest tasks have greatest dual task interference with balance in brain injured adults. Human Movement Science. 2004;23(3-4):489-502. 8. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006. Centers for Disease Control and Prevention website http://www.cdc.gov/traumaticbraininjury/tbi_ed.html. Updated January 7, 2013. Accessed September 28, 2015. 9. Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy. 2003;83(8):713-721. 10. Cantin JF, McFadyen BJ, Doyon J, Swaine B, Dumas D, Vallée M. Can measures of cognitive function predict locomotor behaviour in complex environments following a traumatic brain injury? Brain Injury. 2007;21(3):327-334.   11. Fritz NE, Basso DM. Dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study. Journal of Neurologic Physical Therapy. 2013;37:37-43.  12. Katz-Leurer M, Rotem H, Keren O, Meyer S. Effect of concurrent cognitive tasks on gait features among children post-severe traumatic brain injury and typically-developed controls. Brain Injury. 2011;25(6):581-586.  13. McCulloch KL, Buxton E, Hackney J, Lowers S. Balance, attention, and dual-task performance during walking after brain injury: associations with falls history. The Journal of Head Trauma Rehabilitation. 2010;25(3):155-163. 14. Vallée M, McFayden BJ, Swaine B, Doyon J, Cantin JF, Dumas D. Effects of environmental demands on locomotion after traumatic brain injury. Archives of Physical Medicine and Rehabilitation. 2006;87: 806-13. 15. Zharikova AV, Zhavoronkova LA, Maksakova OA, Kuptsova SV. Characteristics of the performance of a dual task, voluntary postural control, and calculation by patients with consequences of traumatic brain injury. Human Physiology. 2012;38(4):41-50. 16. Traumatic Brain Injury EDGE Task Force. American Physical Therapy Association website http://www.neuropt.org/docs/tbi-edge/tbi-edge-neuro-section-full-edge-documents.pdf?sfvrsn=2. Updated January 2013. Accessed September 24, 2015. 17. Beauchamp M, Dooley J, Anderson V. Adult Outcomes of Pediatric Traumatic Brain Injury. In Donders J, Hunter S. Principles and Practice of Lifespan Developmental Neuropsychology. 315-28. Cambridge University Press. 2010. 18. Hart T, Whyte J, Ellis C, Chervoneva I. Construct validity of an attention rating scale for traumatic brain injury. Neuropsychology. 2009;23(6):729-35.  Lauren Bilski, Kathleen Clancy, Victoria Dean, Danielle Melfi, Kristin Reardon, Louis N. Hunter, PT, DPT Department of Physical Therapy, Jefferson College of Health Professions, Thomas Jefferson University, Philadelphia, PA  

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Application of Dual Task Performance in Pediatrics and Adults with Traumatic Brain Injury: A Systematic Review

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