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Abstract
Background: therapists and nurses often use verbal instruction in the rehabilitation of mobility following stroke.
This study aimed to determine whether performing a verbal cognitive task while walking adversely affected patients'
balance and velocity.
Methods: there were two counterbalanced conditions: walking only and walking and concurrent cognitive activity.
The cognitive activity used was to give one of two verbal responses to two verbal stimuli. An electronic GaitMat
measured gait velocity and balance (double support time as a percentage of stride time).
Results: 11 people with stroke participated in the study (ve women and six men, mean age 72 years, SD 9).
They were on average 120 (SD 48) days post-stroke. Velocity decreased (P = 0.017) and double-support time as
a percentage of stride time increased (P = 0.010) when the cognitive activity was added to the test.
Conclusions: performing a verbal cognitive task while walking adversely affected stroke patients' balance and gait
velocity. Susceptibility to disruption varied within the patient group, suggesting clinical heterogeneity. Further research
is required before changes to clinical practice are justied.
Keywords: cognition, gait, rehabilitation, stroke
Introduction
Relearning to walk independently is a common rehabilitation goal of stroke survivors.
Movement involves not only motor skills, but is also
reliant on sensory and cognitive systems [1]. Therapists
rehabilitating patient mobility following stroke need to
take account of the evidence that cognitive resources are
drawn upon when walking [2] and that this requirement
increases with age [3]. There is also evidence that some
older people stop walking when they talk and that this
phenomenon predicts susceptibility to falling [4].
Therapy should also be informed by a consideration
of what happens to certain aspects of walking, namely
velocity and balance, when additional cognitive demands
are placed on patients as they walk. Many activities in
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A. Bowen et al.
has failed to demonstrate adverse effects on gait speed
or step length [2] or on balance control [6] in healthy
young and older subjects. In the present study, we
aimed to investigate whether `talking while walking'
adversely affected stroke patients' velocity and balance
control.
Hypotheses
320
Results
Participants
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
2
3
4
6
7
8
9
10
11
12
86/F
77/M
85/M
64/F
72/F
74/M
64/M
63/M
61/M
70/F
78/F
Right
Right
n/a
n/a
Left
Left
Left
Right
n/a
Right
Left
50
44
41
56
47
42
55
55
42
55
37
9
8
7
7
10
5
4
7
7
13
12
2
0
4
1
2
0
0
0
28
9
6
Discussion
We found that concurrent verbal cognitive activity
during walking decreased velocity and increased DST%
in a sample of 11 older participants within 7 months of
stroke. In other words, talking while walking slowed
participants' walking speed and disrupted their balance.
Despite the small sample, the results were statistically
signicant. Moreover, the magnitude of the adverse
effects is likely to have clinical signicance. The mean
decrease in velocity equates to )4 m/min, a sizeable
distance for someone who has difculty walking. An
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A. Bowen et al.
Table 2. Changes in mobility due to concurrent verbal activity
Mean value (SD)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Factor
Walking only
Cognitive q walk
Velocity, m/s
DST%
0.64 (0.24)
18.91 (4.60)
0.57 (0.22)
20.92 (5.89)
P-value (two-sided)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
0.017
0.010
Figure 2. A comparison of each participant's doublesupport time (DST) as a percentage of stride time under
`walk only' (3) and `cognitive walk' (q) conditions.
322
Key points
group.
Acknowledgements
This study was funded by The Stroke Association and
the Muriel Edith Rickman Trust. We would like to thank
Pippa Tyrrell and staff on the Stroke Unit for help with
subject recruitment, Marie Hanley for help with data
References
1. Mulder T. The learning machine: ideas about adaptation and
learning following nervous system damage. In Doorenbosch
CAM ed. Learning Motor Skills. Amsterdam: Free University
Press, 1993; 29 44.
2. Lajoie Y, Teasdale N, Bard C, Fleury M. Attentional
demands for static and dynamic equilibrium. Exp Brain Res
1993; 97: 13944.
3. Lajoie Y, Teasdale N, Bard C, Fleury M. Upright standing
and gait: are there changes in attentional requirements related
to normal aging? Exp Aging Res 1996; 22: 18598.
4. Lundin-Olsson L, Nyberg L, Gustafson Y. `Stops walking
when talking' as a predictor of falls in elderly people. Lancet
1997; 349: 617.
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