A systematic review of interventions conducted in clinical or community settings to improve dual-task postural control in older adults

Figures & data

Figure 1 Flowchart of systematic literature search.

Table 1 Level of evidence (n=22)

Study	Level of evidence^Citation32	Design
Hiyamizu et al, 2012^Citation33	1b	RCT
Li et al, 2010^Citation34	1b	RCT
Melzer et al, 2013^Citation35	1b	RCT
Mozolic et al, 2011^Citation36	1b	RCT
Silsupadol et al, 2009A^Citation26	1b	RCT
Silsupadol et al, 2009B^Citation27	1b	RCT
Trombetti et al, 2011^Citation37	1b	RCT
Yamada et al, 2011^Citation38	1b	RCT
Donath et al, 2013^Citation39	2b	Preliminary RCT
Granacher et al, 2010^Citation40	2b	Preliminary RCT
Hall et al, 2009^Citation41	2b	Preliminary RCT
Pichierri et al, 2012^Citation42	2b	Preliminary RCT
Plummer-D’Amato et al, 2012^Citation43	2b	Preliminary RCT
Uemura et al, 2012^Citation44	2b	Preliminary RCT
Verghese et al, 2010^Citation45	2b	Preliminary RCT
You et al, 2009^Citation46	2b	Preliminary RCT
Agmon et al, 2012^Citation47	3	Uncontrolled pretest to posttest
Bisson et al, 2007^Citation48	3	Controlled pretest to posttest
Lajoie et al, 2004^Citation49	3	Controlled pretest to posttest
Melzer et al, 2009^Citation50	3	Case control
Toulotte et al, 2006^Citation51	3	Uncontrolled pretest to posttest
Silsupadol et al, 2006^Citation52	4	Case series

Notes: Levels of evidence: 1a, Systematic review of RCTs; 1b, Individual RCT with narrow confidence interval; 2a, Systematic review of cohort studies; 2b, Individual cohort study or low quality RCT; 3, Individual case-control or pretest-posttest study; 4, Case series or poor quality cohort and case-control studies; 5, Expert opinion.

Abbreviation: RCT, randomized clinical trial.

Table 2 Studies included in the review (n=22)

Study	Sample size, n (sex, F/M)	Group (sample size, n): mean (SD) age, years	Sample characteristics
			Physical	Cognitive	Living situation*	Fall history
Hiyamizu et al 2012^Citation33	36(26/10)	Intervention (17): 72.0(5.1) Control (19): 71.2 (4.4)	Not specified	Not specified	Community-dwelling	With or without risk of falls
Li et al, 2010^Citation34	20(13/7)	Intervention (10): 74.6 (5.7) Control (10): 77.7 (7.1)	Healthy older adults without balance problem	Not specified	Community-dwelling	Without
Melzer et al, 2013^Citation35	66(49/17)	Intervention (33): 78.3 (6.2) Control (33): 75.7 (6.6)	BBS >45 Independently ambulatory: cane acceptable, not walker	MMSE >24	Community-dwelling and in senior living facility	Not specified
Mozolic et al, 2011^Citation36	66(35/31)	Intervention (33): 69.4 (3.2) Control (33): 69.4 (2.5)	Not specified	MMSE ≥5th percentile for participant age and education level	Community-dwelling	Not specified
Silsupadol et al, 2009A^Citation26	21 (17/4)	Single-task (7): 74.7 (7.8) DT fixed priority (8): 74.3 (6.1) DT variable priority (6): 76.0 (4.6)	Balance impairment defined as BBS ≤52 and/or self-selected gait speed ≤ 1.1 m/s	MMSE >24	Community-dwelling	With or without
Silsupadol et al, 2009B^Citation27	21 (17/4)	Single-task (7): 74.7 (7.8) DT fixed priority (8): 74.3 (6.1) DT variable priority (6): 76.0 (4.6)	Balance impairment defined as BBS ≤52 and/or self-selected gait speed ≤ 1.1 m/s	MMSE >24	Community-dwelling	With or without
Trombetti et al, 2011^Citation37	134(129/5)	Early intervention (66): 75.0 (8.0) Delayed intervention (68): 76.0 (6.0)	Increased risk of falling defined by meeting at least one of the following criteria: 1) one or more self-reported falls after age of 65 years; 2) Tinetti Test >2 of 7; 3) one or two criteria of physical frailty	Not specified	Community-dwelling	At risk of fall
Yamada et al, 2011^Citation38	84(65/19)	Intervention (41): 83.0 (6.7) Control (43): 82.9 (5.5)	Ability to walk independently	Rapid Dementia Screening Test ≤4	Community-dwelling	Not specified
Donath et al, 2013^Citation39	18(9/9)	Intervention (9): 71.4 (4.7) Control (9): 73.1 (6.7)	At least moderately active	Not specified	Community-dwelling	Not specified
Granacher et al, 2010^Citation40	20(14/6)	Intervention (11): 71.9 (4.8) Control (9): 74.9 (6.3)	Able to walk without an assistive device	Not specified	Independent, community-dwelling	Not specified
Hall et al, 2009^Citation41	15(10/5)	Intervention (8) Control (7) All participants: 72.2 (7.7); mean and SD not stated by group	Dynamic Gait Index score ≤19	MMSE ≥24	Community-dwelling	With a history of falls or at risk of falls
Pichierri et al, 2012^Citation42	15(9/6)	Intervention (9): 83.6 (3.4) Control (6): 86.2 (4.8)	Able to stand upright for at least 5 minutes	MMSE >22	Care homes	Not specified
Plummer-D’Amato et al, 2012^Citation43	17(16/1)	Dual-Task (10): 76.6 (5.6) Single-Task (7): 76.6 (6.0)	Able to walk independently at least 0.5 m/s without an assistive device	Able to follow three steps command	Community-dwelling	Without
Uemura et al, 2012^Citation44	15(12/3)	Intervention (8): 82.4 (5.9) Control (7): 82.5 (6.8)	Able to walk independently or with cane, no regular exercise in the previous 12 months	Not specified	Community-dwelling	Not specified
Verghese et al, 2010^Citation45	24(15/9)	Intervention (12): 77.4 (7.0) Control (12): 79.9 (7.5)	Sedentary with gait velocity <1.0 m/s	MMSE >25	Community-dwelling	Not specified
You et al, 2009^Citation46	13 (11/2)	Intervention (8) Control (5) All participants: 68.3 (6.5); mean and SD not stated by group	Independently ambulatory	MMSE ≥24	Independent, community-dwelling	At least one fall in the past year
Agmon et al, 2011^Citation47	30 (27/3)	Intervention (30): 74.5 (7.9)	Able to walk 10 meters independently	Not specified	Community-dwelling	Not specified
Bisson et al, 2007^Citation48	24(14/10)	Virtual reality (12): 74.4 (3.7) Bio feedback (12): 74.4 (4.9)	Able to walk without an assistive device	MMSE ≥20	Community-dwelling	Without
Lajoie et al, 2004^Citation49	24 (20/4)	Intervention (12): 70.3 Control (12): 71.4 SD not stated by group	Able to stand and walk without an aid	Not specified	Community-dwelling and residential care facilities	Not specified
Melzer et al, 2009^Citation50	48 (Not specified)	Reporting exercise (24): 8.1 (6.19) Reporting inactive (24): 78.9 (5.1)	Able to walk with no aids	MMSE ≥24	Independent, in retirement homes	Not specified
Toulotte et al, 2006^Citation51	16 (16/0)	With history of falls (8): 71.1 (5.0) Without history of falls (8): 68.4 (4.5)	Able to walk without an assistive device	MMSE ≥24	Not specified	Half with a history of fall within 2 years, half without
Silsupadol et al, 2006^Citation52	3(2/1)	Single-task (1): 82 Dual-task fixed priority (1): 90 Dual-task variable priority (1): 93	Able to walk 9 meters without the assistance of another person	MMSE ≥24	Independent	With

Notes:

* The papers defined the living situation of study’s participants differently. Here we used their definition.

Abbreviations: BBS, Berg Balance Scale; F, female; M, male; MMSE, mini-mental state exam; m/s, meters per second; SD, standard deviation.

Table 3 Study characteristics (n=22)

Study	Protocol			Setting	Content (by group)
	Time (minutes)	Frequency	Duration
Hiyamizu et al, 2012^Citation33	60	Two times weekly	12 weeks	Group setting	1) Intervention: calculations, visual searches, and verbal fluency tasks were performed simultaneously during the balance training 2) Control: strength, balance, and walking training
Li et al, 2010^Citation34	60	Five sessions at least 2 days apart	Approximately 5 weeks	Group setting (four to six people)	1) Intervention: computerized cognitive dual-task training: visual discrimination tasks 2) Control: no intervention
Melzer et al, 2013^Citation35	60	Two times weekly	24 weeks	Group setting	1) Intervention: balance exercise in five different levels including perturbation and dual-task exercise 2) Control: no intervention
Mozolic et al, 2011^Citation36	60	One time weekly	8 weeks	Individual training	1) Intervention: cognitive training focused on visual and auditory selective attention 2) Control: education lectures
Silsupadol et al, 2009A^Citation26	45	Three times weekly	4 weeks	One on one	1) Single-task balance training 2) Dual-task balance training with fixed priority instructions 3) Dual-task balance training with variable priority instructions
Silsupadol et al, 2009B^Citation27	45	Three times weekly	4 weeks	One on one	1) Single task balance training 2) Dual-task balance training with fixed priority instructions 3) Dual-task balance training with variable priority instructions
Trombetti et al, 2011^Citation37	60	One time weekly	25 weeks	Group setting	1) Multitask exercises based on Jaques-Dalcroze music education (eg, walking in time to music, responding to changes in music, walk and turn, exaggerated upper body movements)
Yamada et al, 2011^Citation38	20	Two times weekly	24 weeks	Group setting	1) Intervention: DVD seated based exercise, 15 minutes regular exercise, and 5 minutes dual-task verbal fluency while sitting and stepping 2) Control: no intervention
Donath et al, 2013^Citation39	60	Two times weekly	6 weeks	Group setting	1) Intervention: specific progressive fall training includes martial arts and different falls on different mats 2) Control: three educational lessons on fall prevention knowledge
Granacher et al, 2010^Citation40	60	Three times weekly	6 weeks	Group setting	1) Balance training (standing on unstable surfaces, single leg stance with increased flexion, catching and throwing a ball)
Hall et al, 2009^Citation41	90 Tai Chi 60 control	Two times weekly	12 weeks	Group setting	1) Intervention: Tai Chi 2) Control: health-related topics
Pichierri et al, 2012^Citation42	60	Two times weekly	12 weeks	Group setting	1) Progressive resistance training, progressive postural balance training, progressive dance video gaming
Plummer-D’Amato et al, 2012^Citation43	45	One time weekly	4 weeks	Group setting	1) Intervention: balance, gait, and agility. The balance and gait activity combined with simultaneously cognitive tasks (number generation, word association, backward recitation, and working memory) 2) Control: balance, gait, and agility
Uemura et al, 2012^Citation44	35	One time weekly	24 weeks	Group setting for 30 minutes plus 5 minutes dual-task training	The intervention and control received 30 minutes of regular exercises. At the end of each session, each group received 5 minutes of different dual-task exercises: 1) Intervention: dual-task switch exercises 2) Control: steady state gait under dual-task
Verghese et al, 2010^Citation45	24	Three times weekly at least 1 day apart	8 weeks	Individual training	1) Intervention: computerized cognitive training: auditory and cross modality tasks aimed at training attention and executive function 2) Control: received information about the importance of physical activity
You et al, 2009^Citation46	30	Five times weekly	18 total sessions over 6 weeks	One on one	1) Walking with cognitive task (memorizing and computing tasks) 2) Walking while listening to music
Agmon et al, 2012^Citation47	60	Three times weekly	6 weeks	Group setting	1) Enhance Fitness training
Bisson et al, 2007^Citation48	30	Two times weekly	10 weeks	One on one	1) Virtual reality (“juggling” a virtual ball) 2) Visual biofeedback (COP position)
Lajoie et al, 2004^Citation49	60	Two times weekly	8 week	One on one	1) Computerized feedback and postural training
Melzer et al, 2009^Citation50	60	Three times weekly	3 years	Group setting	1) General training (Tai Chi, Feldenkreis, walking)
Toulotte et al, 2006^Citation51	60	Two times weekly	3 months	Group setting	1) Exercise program: strengthening, flexibility, static balance, dynamic balance
Silsupadol et al, 2006^Citation52	45	Three times weekly	4 weeks	One on one	1) Single task balance training 2) Dual-task balance training with fixed priority instructions 3) Dual-task balance training with variable priority instructions

Abbreviation: COP, center of pressure.

Table 4 Study outcomes (n=22)

Study	Assessment points	Dual-task performance measures	Results	Dual-task improvement
Hiyamizu et al, 2012^Citation33	1) Pretest 2) Posttest	1) Sway length of COG while performing Stroop test 2) The rate of Stroop task (accurate number/total numbers × 100) while maintaining standing position on a force plate	1) Nonsignificant improvement 2) Significant improvement in the intervention group	Yes, cognitive under dual-task
Li et al, 2010^Citation34	1) Pretest	Each physical outcome was tested concurrently with n-back working memory task:		Yes, motor under dual-task
	2) Posttest	1) Single support standing balance with eyes open and closed (four trials each) and involved standing on the dominant leg for 10 seconds per trial 2) Double-support standing balance under three conditions: stable platform, visual surround sway, and platform sway 3) Sit to stand test 4) Gait speed	1) Significant improvement 2) Significant improvement 3) Nonsignificant improvement 4) Nonsignificant improvement
Melzer et al, 2013^Citation35	1) Pretest 2) Posttest	Voluntary step execution test under dual-task	Significant improvement	Yes, motor
Mozolic et al, 2011^Citation36	1) Pretest 2) Posttest	Walking while reciting words, measured number of recited words	Number of words recited significantly improved Dual-task cost did not improve	Yes, cognitive
Silsupadol et al, 2009A^Citation26	1) Pretest	1) Narrow-base walking with serial-3 subtractions (trained dual-task condition):		Yes, both cognitive and walking tasks (for the trained task only) under dual-task
	2) Posttest	a) Walking: COM-AJC  b) Serial-3 subtractions: response rate and number of errors	a) Improved for all groups with greatest improvement for those trained with variable priority instructions  b) Response rate improved only in the VP group; number of errors did not differ between groups
		2) Obstacle crossing with auditory Stroop task (novel dual-task condition):
		a) Walking: COM-AJC  b) Auditory Stroop task: verbal reaction time	a) Did not improve for any group  b) Did not improve for any group
Silsupadol et al, 2009B^Citation27	1) Pretest 2) After 2 weeks 3) Posttest 4) 12 weeks after the intervention	Gait speed (while responding to addition/subtraction questions)	Improved for the trained dual-task groups (variable priority and fixed priority) but not for the control group (single-task)	Yes, motor under dual-task
Trombetti et al, 2011^Citation37	1) Pretest	Walking in self-selected, slow and fast speeds while counting backward by one from 50:		Yes, motor under dual-task
	2) Posttest 3) 12 months	1) Gait speed: gait velocity, stride length, cadence 2) Dynamic balance: double support %, step width 3) Gait variability: stride time variability, stride length variability	1) Stride length improved in the intervention group after 6 months 2) No significant changes 3) Decrease in stride length variability after 6 months, maintained at 12 months
Yamada et al, 2011^Citation38	1) Pretest 2) Posttest	Gait speed while walking 10 meters carrying a ball on a tray. Dual-task cost calculated for both tasks	Walking time under manual task improved Dual-task cost improved for walking task	Yes, motor
Donath et al, 2013^Citation39	1) Pretest 2) Posttest	1) AP and ML (COP) under motor dual-task 2) Gait variability with motor dual-task	Improvement only for the intervention group in both dual-tasks measure	Yes, motor
Granacher et al, 2010^Citation40	1) Pretest 2) Posttest	1) Gait velocity under dual and triple tasks 2) Cognitive performance while walking 3) Motor performance while walking (contact ring time)	1) Nonsignificant improvement 2) Nonsignificant improvement 3) Significant improvement in the intervention group but not in the control group	Yes, motor under dual-task
Hall et al, 2009^Citation41	1) Pretest 2) Posttest	Dual-task cost for postural and cognitive measures	Nonsignificant improvement	No
Pichierri et al, 2012^Citation42	1) Pretest 2) Posttest	Voluntary step execution test under dual-task condition	Significant improvement of initiation time of forward and backward steps execution	Yes, motor
Plummer-D’Amato et al, 2012^Citation43	1) Pretest 2) Posttest	6 minutes obstacle negotiation under single and dual-task (dual-task cost calculated for each task)	Nonsignificant improvement	No improvement
Uemura et al, 2012^Citation44	1) Pretest 2) Posttest	1) Gait initiation under dual-task 2) Steady state gait (10 meters) under dual-task	1) Improvement only for the intervention group 2) Improvement for both groups but more effective for the intervention group	Yes, motor under dual-task
Verghese et al, 2010^Citation45	1) Pretest 2) Posttest	Gait velocity while talking: reciting the alternate alphabet	Significant improvement	Yes, motor under dual-task
You et al, 2009^Citation46	1) Pretest 2) Posttest	1) Gait velocity under dual-task 2) AP and ML (COP) 3) Memory performance data	1) Nonsignificant improvement in the intervention group, but significant improvement in the control group 2) Nonsignificant improvement in AP and ML COP 3) Significant improvement in the intervention group but not in the control group	Yes, cognitive under dual-task
Agmon et al, 2012^Citation47	1) Pretest 2) Posttest	1) Timed Up and Go cognitive and 1 minute walk with verbal fluency  a) Gait speed and walking under two tests  b) Dual-task cost for walking  c) Dual-task cost cognitive	a) Significant improvement for both tests  b) Nonsignificant improvement for both tests  c) Significant improvement for the Timed Up and Go and decline for 1 minute walk with verbal fluency	No
Bisson et al, 2007^Citation48	1) Pretest 2) Posttest 3) 1 month after intervention	1) Reaction time under dual-task condition 2) Postural sway under dual-task conditions	1) Significant improvement in both groups at posttest and 1 month follow-up 2) No training effect	Yes, cognitive under dual-task
Lajoie et al, 2004^Citation49	1) Pretest 2) Posttest 3) 2 weeks after intervention	1) Reaction time under dual-task condition 2) Postural sway under dual-task condition	1) Significant improvement in the intervention group at posttest and 2 week follow-up compared to pretest, but not in the control group 2) Nonsignificant improvement	Yes, cognitive under dual-task
Melzer et al, 2009^Citation50	1) Single posttest measurement	Voluntary step execution test under dual-task	Only the preparation phase of dual-task step execution was faster in the exercise group compared to the control group	No improvement
Toulotte et al, 2006^Citation51	1) 3 months before training (T0) 2) 2 days before training (T1) 3) 2 days after training (T2) 4) 3 months after training (T3)	1) Timed Up and Go while holding glass full of water:  a) Walking speed  b) Stride time  c) Single support time  d) Cadence  e) Stride length	a) T0 to T1: no change for either group; T1 to T2: increased for both groups; T2 to T3: decreased for both groups  b) T0 to T1: no change for either group; T1 to T2: decreased for both groups;T2 to T3: increased for both groups  c) T0 to T1: increased for both groups; T1 to T2: decreased for both groups; T2 to T3: increased for both groups  d) T0 to T1: no change for either group; T1 to T2: increased for both groups; T2 to T3: decreased for nonfallers  e) T0 to T1: no change for either group; T1 to T2: increased for both groups;T2 to T3: decreased for both groups	Yes, motor under dual-task
Silsupadol et al, 2006^Citation52	1) Pretest 2) After 2 weeks 3) 12 weeks after intervention	Timed Up and Go cognitive	Significant improvement in all three participants. Greater improvement in the dual-task training participants	Yes, both cognitive and motor under dual-task

Abbreviations: AP and ML COP, anterior–posterior and medial–lateral center of pressure; COM-AJC, center of mass-ankle joint center inclination; VP, variable priority; COG, center of gravity.

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