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The effect of dual task activities on the walking gait of individuals with Parkinson's disease.


Approximately 4 million people worldwide are diagnosed with Parkinson's disease (PD) with this number increasing each year (4). PD is a degenerative disease that affects the dopamine producing cells of the substantia nigra within the basal ganglia (9). Signs of PD include bradykinesia, tremor, muscle rigidity, and instability of gait (9). The severity varies from person to person, thus effects gait patterns differently with the more severe cases having greater gait disturbances (4). Gait and balance impairment can be displayed even in the early stages of PD (5). In fact 50-68% of those with PD are reported to fall each year (4).

Dual tasking is important for functional mobility in the home and community, with safe and efficient ambulation serving as a key factor (4). Dual tasking may include thinking while walking, carrying an object from one area to another, or even holding an object while maintaining balance (4). Restrictions in this area can limit performance of activities of daily living, increase risk of falls and negatively affect quality of life (5). When asked to dual task during ambulation, those with PD show a reduction in stride length, have more freezing episodes, and a greater stride-to-stride variability which all contribute to increased fall risk (4). The majority of falls suffered by those with PD each year occur during ambulation and elderly persons with PD are nine times more likely to fall than elderly individuals without PD (4,5). During DTGT, one task runs through the frontal cortex region while the other runs through the basal ganglia (4). The task through the frontal cortex is able to stay under control with normal speed whereas the task through the basal ganglia, which becomes defective with PD, may be slower or show error (4). Physical exercise has been shown to have a positive effect on managing PD with potential "neuroprotective mechanisms" (5). Balance and gait training have produced promising results in maintaining function (5). Medications, such as levodopa, are used to treat PD and gait impairment, however becomes less effective overtime (4). Brauer, Woollacott, Lamont et al. (2011) and Earhart (2009) promote the idea that dual task exercise therapy involving gait training and strength training may effectively address gait disturbances (4,7). Mirelman, Maidan, Herman et al. (2011) advocates virtual reality training over traditional gait training because it teaches the individual motor skills while training in a challenging and complex environment (10).

The purpose of this literature review is to explore the effects of DTGT on those with PD.


A comprehensive review of literature was performed using the following search engines (PubMed, CINAHL, EBSCO, MedScape, HealthWebb and Google Scholar). The key words and phrases used in the search were many combinations of the following (Parkinson's disease, gait problems, dual tasking, Parkinson's dual tasking and gait training with Parkinson's disease). The literature was then narrowed to scientific literature concerning the effects of dual task activities on the walking gait of those with Parkinson's disease. Papers were limited to those published in 2000 and after.


Bond and Morris (2000) conducted a study focusing on goal-directed tasks and how it affects the gait of individuals with in PD (2). These tasks included walking freely, walking while carrying a tray, and walking while carrying a tray with 4 plastic glasses (2). Twelve participants with PD were compared to 12 participants without PD in gait speed, stride length, and cadence while completing each task (2). The results showed that participants with PD walked more slowly in every category than those without PD and that walking with glasses on the tray demonstrated greater decreases in speed and stride length than walking freely and walking with a tray (2). The mean gait speed for those with PD walking freely was 69.25m/min, walking with a tray was 68.01m/min, and walking with glasses on the tray was 61.69m/min (2). The mean stride length for those with PD walking freely was 1.27m, walking with a tray was 1.24m, and walking with glasses on a tray was 1.14m (2). The mean cadence for those with PD walking freely was 109.64 steps/min, walking with a tray was 110.90 steps/min, and walking with glasses on a tray was 108.56 steps/min (2). The mean gait speed for those without PD walking freely was 82.61 m/min, walking with a tray was 82.48m/min, and walking with glasses on a tray was 81.25m/min (2). The mean stride length for those without PD walking freely was 1.51m, walking with a tray was 1.50m, and walking with glasses on a tray was 1.48m. The cadence for those without PD walking freely was 109.37 steps/min, walking with a tray was 109.79 steps/min, and walking with glasses on a tray was 109.82 steps/min (2).

Several studies researched DTGT to determine how it effects the gait of those with PD. Brauer and Morris (2010) studied the effects of gait training combined with cognitive memory tasks. Twenty participants with a mean age of 68.5 years and with PD completed a 20-minute DTGT session measuring stride length, speed, and cadence (3). Participants served as both control and intervention groups to assure homogeneity within the study groups. The tasks given to perform while walking were carrying a tray with four glasses on it, transferring coins from one pocket to the other, recalling words starting with certain letters, and counting backwards by 3 s (3). The participants stride length decreased when an additional task was added to walking. After DTGT with emphasis on increasing stride length, those with PD increased stride length (p < 0.001), and gait speed (p = 0.01) while performing dual tasks except for carrying a tray of glasses (3). Cadence did not change with training (p > 0.280) (3).

Yogev-Seligmann, Rotem-Galili, Dickstein et al. (2012) focused on cognitive tasks such as verbal cueing and information processing while walking. For one month, 20 individuals with a mean age of 70.9 years with PD and 20 age-matched adults without PD participated in DTGT. The participants received verbal cues to prioritize either cognitive tasks (verbal fluency/reciting as many words as possible starting with a specific letter) or gait tasks (focus on aspects of gait cycle/stride length, walking speed, etc) (12). Significant changes were seen in both groups (p < 0.001) during task prioritizations. Gait prioritization caused increased walking speeds in both groups while prioritization of cognitive tasks caused decreased gait speed in both groups (12).

Baker, Rochester and Nieuwboer (2007) studied the effects of verbal cueing on gait training. Participants with PD were evaluated on walking speed, stride length, and step frequency (1). Fifteen participants with PD were compared to 12 participants without PD. Verbal cueing such as "as you walk try to take big steps" was used with the PD participants increasing speed by 9.5% (p < 0.001), stride length by 15% (p < 0.001) and step frequency by 6% (p = 0.042) (1).

Fok, Farrell and McMeeken (2010) studied the short term effectiveness of gait prioritization on individuals with PD (8). Twelve participants, all with PD were divided into a training group, 6 adults with a mean age of 73 years and a control group, 6 adults with a mean age of 66.3 years. The primary focus was to place the attention of participants on taking longer steps instead of focusing on the cognitive tasks being performed. The training group received 30 minutes of training by completing numerical subtractions while walking and the control group sat and read a magazine for the same time period. The training group showed improvement in stride length (p = 0.001) and gait velocity (p = 0.05) compared to baseline scores and also when compared to controls (p = 0.001) and (p = 0.001) respectively (8). The effects were maintained by those trained for 30 minutes (8).

Earhart (2009) conducted a review of literature concerning the use of dance as a form of therapy for those with PD. Dance was performed with music as an external cue to promote movement (7). The various studies reviewed introduced specific movement patterns that promoted gait training such as the Argentine tango, which enhanced backwards walking, balance, and walking speed (7). This form of therapy required an individual to dual task by recalling and performing movement patterns assigned to specific types of music.

Most studies involved dance therapy twice weekly for 60-90 minutes duration and a time span of 6-12 weeks. Individuals with PD were shown to improve in balance as evidenced by an average 4 point improvement in the Berg Balance Scale and in functional mobility by a mean 1 second improvement in the Timed Up and Go Test which involves sit to stand and walking (7). Earhart concluded that while more research is needed to examine the long term effects of dance activities on those with PD, dance may be an effective alternative to traditional exercise programs when addressing movement problems of those with PD (7).

De Bruin, Doan, Turnbell et al. (2010) conducted a study to determine if listening to music was a safe and effective tool to use during gait training in those with PD (6). Twenty-two elderly participants with PD were evaluated for 13 weeks in either a control group (mean age 67.0 years) or a music group (mean age 64.1 years) (6). The control group continued with their regular activities whereas the music group walked for 30 minutes, three times a week while listening to preferred music through head-phones (6). Music tempo was selected based on the individual's normal cadence (6). At the end of 13 weeks, the music group improved in gait velocity (p = 0.002), stride time (p = 0.19), and cadence (p = 0.007) while the control group remained the same (p > 0.05) (6).

In 2012 Pompeu, Mendes, da Silva, et al. (2012) utilized Nintendo Wii games as a modern approach to DTGT. Thirty-two people with PD from ages 60-85 years were divided into the Wii games group (n = 16) and the traditional balance exercise group (n = 16). The training sessions were 1 hour per day, twice per week for 7 weeks (11). The first 30 minutes focused on global strengthening exercises and the last 30 minutes focused on balance exercise therapy (traditional for the controls and Wii games that involve balance activities for the experimental group) (11). The games consisted of decision-making, strategy, static balance, dynamic balance, and stationary gait (11). The results of this study showed significant increases in balance activities with both the Wii virtual training group and the balance exercise group. Overall, Wii-based motor and cognitive training resulted in improvement in independent performance of activities of daily living, balance and cognition, however there was no significant difference between the experimental and control groups at the end of training or 60 days post-training (p > 0.05) (11).


Many activities of daily living require the ability to perform multiple tasks during walking. While PD can have negative effects on walking gait as a single task, Bond and Morris demonstrated that the addition of a secondary task results in further detriment to the gait cycle i.e. decreased speed and stride length (2). As the effects become more pronounced, decreased gait efficiency can result in the increased risk of falls. Fortunately, various methods of practicing dual tasks, DTGT, have been shown to decrease these detrimental effects on the gait cycle of individuals with PD. Typically, gait speed, stride length, cadence and balance have been found to be improved with DTGT using verbal cues to prioritize focus on the specifics of the walking gait (1,3,8,12). Interestingly, they all showed an increased ability to perform secondary tasks with DTGT.

Earhart and de Bruin et al. demonstrated a unique form of DTGT with the combination of gait patterns and rhythmic music which also produced positive effects on dual task walking (6,7). Finally Pompeu et al. introduced Wii Fit games as a fun alternative method of enhancing balance and performance of activities of daily living (11). The results of this literature review although not exhaustive in nature, provides ample support for the theory that while the effects of PD decrease an individual's ability to dual task, DTGT can at least partially offset the negative effects. Thus, the implications of these studies include a variety of options available for the clinician to assist in the improvement of dual tasks for individuals with PD including alternative methods of DTGT via the introduction of music and Wii-Nintendo games. The key to DTGT as described by Yoge-Seligmann et al. is that those with PD be relatively intact cognitively in order to be able to institute prioritization of task (12). However, further study is needed to determine how to optimize DTGT for those with PD.

Conflict of Interest

The authors of this manuscript report no conflict of interest.


(1.) Baker, K., Rochester, L., and Nieuwboer, A. The immediate effect of attentional, auditory, and a combined cue strategy on gait during single and dial tasks in Parkinson's disease. Archives of physical medicine and rehabilitation. 88(12):1593-1600, 2007.

(2.) Bond, J., and Morris, M. Goal-directed secondary motor tasks: their effects on gait in subjects with Parkinson disease. Archives of physical medicine and rehabilitation. S7(1): 110-116, 2000.

(3.) Brauer, S. G., and Morris, M. E. (2010). Can people with Parkinson's disease improve dual tasking when walking? Gait & posture. 31 (2):229-233, 2010.

(4.) Brauer, S. G., Woollacott, M. H., Lamont, R., Clewett, S., OSullivan, J., Silburn, P., Mellick, G. D., and Morris, M. E. Single and dual task gait training in people with Parkinson's. BMC Neurology. 11 (1):90-95, 2011.

(5.) Conradsson, D., Lofgren, N., Stahle, A., Hagstromer, M., and Franzen, E. A novel conceptual framework for balance training in Parkinson's disease-study protocol for a randomised controlled trial. BMC Neurology. 12:111, 2012.

(6.) de Bruin, N., Doan, J. B., Turnbull, G., Suchowersky, O., Bonfield, S., Hu, B., and Brown, L. (2010). Walking with music is a safe and viable tool for gait training in Parkinson's disease: the effect of a 13-week feasibility study on single and dual task walking. Parkinson's disease, 2010. Retrieved from 957229/

(7.) Earhart, G. M. Dance as therapy for individuals with Parkinson disease. European journal of physical and rehabilitation medicine. 45.2:231, 2009.

(8.) Fok, P., Farrell. M., McMeeken, J. Prioritizing gait in dual-tasking conditions in people with Parkinson's. Human Movement Science. 29: 831-842, 2010.

(9.) Foley, J., Kaschel, R., and Sala, S. Dual task performance in Parkinson's disease. Behavioral Neurology, 27:183-191, 2013.

(10.) Mirelman, A., Maidan, I., Herman, T., Deutsch, J., Giladi, N., and Hausdorff, J. Virtual reality for gait training: Can it induce motor learning to enhance complex walking and reduce fall risk in patients with Parkinson's disease? Gerontol A Biol Sci Med Sci, 66A(2): 234-240, 2011.

(11.) Pompeu, J., Mendes, F., da Silva, K., Lobo, A., Oliveria, T., Zomignani, A., and Piemonte, M. Effect of Nintendo wii-based motor and cognitive training on activities of daily living in patients with Parkinson's disease: a randomized clinical trial. Physiotherapy, 98(3): 196-204, 2012.

(12.) Yogev-Seligmann, G., Rotem-Galili, Y., Dickstein, R., Giladi, N. and Hausdorff, J. M. Effects of explicit prioritization on dual task walking in patients with Parkinson's disease. Gait & Posture, 35:641-646, 2012.

Morgan M. Ford, SKT [1], Jeffrey B. Howell, SKT [1], Ben C. Moore, SKT [1], Samara T. St. Aimie, SKT [1], LaCraig C. Cook, SKT [1], Kelsi R. Weaver, SKT [1], David R. Dolbow, PhD, DPT, RKT [2]

[1] University of Southern Mississippi, Human Performance and Recreation Dept., Hattiesburg, MS, Kinesiotherapy student

[2] University of Southern Mississippi, Human Performance and Recreation Dept., Hattiesburg, MS, Assistant Professor


David Dolbow

4209 New Hope Meadow Rd Hermitage, TN 37076 615-513-0279 (Cell) 601-266-1000 (Work)
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Title Annotation:Clinician's Corner
Author:Ford, Morgan M.; Howell, Jeffrey B.; Moore, Ben C.; St. Aimie, Samara T.; Cook, LaCraig C.; Weaver,
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Report
Date:Mar 22, 2015
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