Effects of Dual Task Training on Dual Task Gait Performance and Cognitive Function in Individuals With Parkinson Disease: A Meta-analysis and Meta-regression

Published:November 26, 2022DOI:



      To explore the effects of dual task (DT) training on DT gait performance and cognitive function in individuals with Parkinson disease (PD) and to examine factors that might influence the effects of DT training.

      Data Sources

      PubMed, Wiley Online Library, Cochrane Library, CINAHL, and Medline were searched for articles published from January 2006 to December 2021.

      Study Selection

      Randomized controlled trials comparing DT training with usual care or general exercise were included.

      Data Extraction

      The outcomes studied were DT gait parameters including speed, step and stride length, cadence, step and stride time variability, dual-task cost on gait speed, and Trail Making Tests presented as standardized mean differences (SMDs). The Grading of Recommendations, Assessment, Development, and Evaluation was used to evaluate the quality of evidence.

      Data Synthesis

      Ten randomized controlled trials with 466 participants were included in the meta-analysis. The included studies presented, in general, with a low to high risk of bias. Meta-analyses used a random-effects model for all analyses. The meta-analysis showed the DT training effects on DT gait speed (SMD=0.825, P=.012), DT step and stride length (SMD=0.400, P=.015), Trail Making Tests-part A (TMT-A; SMD=0.533, P=.010), and Trail Making Tests-part B (SMD=0.516, P=.012) compared with the control group. Only the effect on TMT-A was maintained at the follow-up assessment. The results of meta-regression showed that participants with slower initial single task gait speed improved more after DT training on DT step and stride length.


      The DT training improved more in DT gait speed with moderate-quality evidence as compared with usual care or conventional physical training in individuals with PD. The beneficial effects of DT training on DT step and stride length, attention, and executive function were also demonstrated in this meta-analysis. Furthermore, the improvement in the DT walking step and stride length was related to the participant's initial single task gait speed.


      List of abbreviations:

      CI (confidence interval), DT (dual task), DTC (dual-task cost), GRADE (Grading of Recommendations Assessment, Development and Evaluation), PD (Parkinson disease), SMD (standardized mean difference), TMT-A (Trail Making Tests-part A), TMT-B (Trail Making Tests-part B), RCT (randomized controlled trial)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Wilson J
        • Alcock L
        • Yarnall AJ
        • et al.
        Gait progression over 6 years in Parkinson disease: effects of age, medication, and pathology.
        Front Aging Neurosci. 2020; 12577435
        • Williams AJ
        • Peterson DS
        • Earhart GM.
        Gait coordination in Parkinson disease: effects of step length and cadence manipulations.
        Gait Posture. 2013; 38: 340-344
        • Zanardi APJ
        • da Silva ES
        • Costa RR
        • et al.
        Gait parameters of Parkinson's disease compared with healthy controls: a systematic review and meta-analysis.
        Sci Rep. 2021; 11: 752
        • Paul SS
        • Sherrington C
        • Canning CG
        • Fung VS
        • Close JC
        • Lord SR.
        The relative contribution of physical and cognitive fall risk factors in people with Parkinson's disease: a large prospective cohort study.
        Neurorehabil Neural Repair. 2014; 28: 282-290
        • Creaby MW
        • Cole MH.
        Gait characteristics and falls in Parkinson's disease: a systematic review and meta-analysis.
        Parkinsonism Relat Disord. 2018; 57: 1-8
        • Aarsland D
        • Batzu L
        • Halliday GM
        • et al.
        Parkinson disease-associated cognitive impairment.
        Nat Rev Dis Primers. 2021; 7: 47
        • Yogev-Seligmann G
        • Hausdorff JM
        • Giladi N.
        The role of executive function and attention in gait.
        Mov Disord. 2008; 23: 329-342
        • Stegemöller EL
        • Wilson JP
        • Hazamy A
        • et al.
        Associations between cognitive and gait performance during single- and dual-task walking in people with Parkinson disease.
        Phys Ther. 2014; 94: 757-766
        • Maidan I
        • Nieuwhof F
        • Bernad-Elazari H
        • et al.
        The role of the frontal lobe in complex walking among patients with Parkinson's disease and healthy older adults: an fNIRS study.
        Neurorehabil Neural Repair. 2016; 30: 963-971
        • Wild LB
        • de Lima DB
        • Balardin JB
        • et al.
        Characterization of cognitive and motor performance during dual-tasking in healthy older adults and patients with Parkinson's disease.
        J Neurol. 2013; 260: 580-589
        • Raffegeau TE
        • Krehbiel LM
        • Kang N
        • et al.
        A meta-analysis: Parkinson's disease and dual-task walking.
        Parkinsonism Relat Disord. 2019; 62: 28-35
        • Salazar RD
        • Ren X
        • Ellis TD
        • et al.
        Dual tasking in Parkinson's disease: cognitive consequences while walking.
        Neuropsychology. 2017; 31: 613-623
        • Yamada PA
        • Amaral-Felipe KM
        • Spinoso DH
        • Abreu DCC
        • Stroppa-Marques AEZ
        • Faganello-Navega FR.
        Everyday tasks impair spatiotemporal variables of gait in older adults with Parkinson's disease.
        Hum Mov Sci. 2020; 70102591
        • de Souza Fortaleza AC
        • Mancini M
        • Carlson-Kuhta P
        • et al.
        Dual task interference on postural sway, postural transitions and gait in people with Parkinson's disease and freezing of gait.
        Gait Posture. 2017; 56: 76-81
        • Plotnik M
        • Giladi N
        • Dagan Y
        • Hausdorff JM.
        Postural instability and fall risk in Parkinson's disease: impaired dual tasking, pacing, and bilateral coordination of gait during the “ON” medication state.
        Exp Brain Res. 2011; 210: 529-538
        • Elshehabi M
        • Maier KS
        • Hasmann SE
        • et al.
        Limited effect of dopaminergic medication on straight walking and turning in early-to-moderate Parkinson's disease during single and dual tasking.
        Front Aging Neurosci. 2016; 8: 4
        • Sun C
        • Armstrong MJ.
        Treatment of Parkinson's disease with cognitive impairment: current approaches and future directions.
        Behav Sci (Basel). 2021; 11: 54
        • Strouwen C
        • Molenaar EA
        • Münks L
        • et al.
        Dual tasking in Parkinson's disease: should we train hazardous behavior?.
        Expert Rev Neurother. 2015; 15: 1031-1039
        • Bratzke D
        • Rolke B
        • Ulrich R.
        The source of execution-related dual-task interference: motor bottleneck or response monitoring?.
        J Exp Psychol Hum Percept Perform. 2009; 35: 1413-1426
        • Wulf G
        • McNevin N
        • Shea CH.
        The automaticity of complex motor skill learning as a function of attentional focus.
        Q J Exp Psychol A. 2001; 54: 1143-1144
        • Schubert T
        • Strobach T.
        Practice-related optimization of dual-task performance: efficient task instantiation during overlapping task processing.
        J Exp Psychol Hum Percept Perform. 2018; 44: 1884-1904
        • Strobach T
        • Torsten S.
        Mechanisms of practice-related reductions of dual-task interference with simple tasks: data and theory.
        Adv Cogn Psychol. 2017; 13: 28-41
        • Conradsson D
        • Löfgren N
        • Nero H
        • et al.
        The effects of highly challenging balance training in elderly with Parkinson's disease: a randomized controlled trial.
        Neurorehabil Neural Repair. 2015; 29: 827-836
        • Strouwen C
        • Molenaar EALM
        • Münks L
        • et al.
        Training dual tasks together or apart in Parkinson's disease: results from the DUALITY trial.
        Mov Disord. 2017; 32: 1201-1210
        • Beck EN
        • Intzandt BN
        • Almeida QJ.
        Can dual task walking improve in Parkinson's disease after external focus of attention exercise? A single blind randomized controlled trial.
        Neurorehabil Neural Repair. 2018; 32: 18-33
        • Geroin C
        • Nonnekes J
        • de Vries NM
        • et al.
        Does dual-task training improve spatiotemporal gait parameters in Parkinson's disease?.
        Parkinsonism Relat Disord. 2018; 55: 86-91
        • Vergara-Diaz G
        • Osypiuk K
        • Hausdorff JM
        • et al.
        Tai Chi for reducing dual-task gait variability, a potential mediator of fall risk in Parkinson's disease: a pilot randomized controlled trial.
        Glob Adv Health Med. 2018; 72164956118775385
        • Yang YR
        • Cheng SJ
        • Lee YJ
        • Liu YC
        • Wang RY.
        Cognitive and motor dual task gait training exerted specific training effects on dual task gait performance in individuals with Parkinson's disease: a randomized controlled pilot study.
        PLoS One. 2019; 14e0218180
        • Löfgren N
        • Conradsson D
        • Rennie L
        • Moe-Nilssen R
        • Franzén E.
        The effects of integrated single- and dual-task training on automaticity and attention allocation in Parkinson's disease: a secondary analysis from a randomized trial.
        Neuropsychology. 2019; 33: 147-156
        • Vieira-Yano B
        • Martini DN
        • Horak FB
        • et al.
        The adapted resistance training with instability randomized controlled trial for gait automaticity.
        Mov Disord. 2021; 36: 152-163
        • San Martín Valenzuela C
        • Moscardó LD
        • López-Pascual J
        • Serra-Añó P
        • Tomás JM.
        Effects of dual-task group training on gait, cognitive executive function, and quality of life in people with Parkinson disease: results of randomized controlled DUALGAIT trial.
        Arch Phys Med Rehabil. 2020; 101: 1849-1856
        • Jung SH
        • Hasegawa N
        • Mancini M
        • et al.
        Effects of the agility boot camp with cognitive challenge (ABC-C) exercise program for Parkinson's disease.
        NPJ Parkinsons Dis. 2020; 6: 31
        • Fritz NE
        • Cheek FM
        • Nichols-Larsen DS.
        Motor-cognitive dual-task training in persons with neurologic disorders: a systematic review.
        J Neurol Phys Ther. 2015; 39: 142-153
        • De Freitas TB
        • Leite PHW
        • Doná F
        • Pompeu JE
        • Swarowsky A
        • Torriani-Pasin C.
        The effects of dual task gait and balance training in Parkinson's disease: a systematic review.
        Physiother Theory Pract. 2020; 36: 1088-1096
        • Li Z
        • Wang T
        • Liu H
        • Jiang Y
        • Wang Z
        • Zhuang J.
        Dual-task training on gait, motor symptoms, and balance in patients with Parkinson's disease: a systematic review and meta-analysis.
        Clin Rehabil. 2020; 34: 1355-1367
        • Fernández-Lago H
        • Bello O
        • López-Alonso V
        • Sánchez JA
        • Morenilla L
        • Fernández-del-Olmo MÁ.
        Gait pattern and cognitive performance during treadmill walking in Parkinson disease.
        Am J Phys Med Rehabil. 2015; 94: 931-940
        • Moher D
        • Liberati A
        • Tetzlaff J
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151: 264-269
        • Beauchet O
        • Berrut G.
        Marche et double tâche: définition, intérêts et perspectives chez le sujet âgé [Gait and dual-task: definition, interest, and perspectives in the elderly].
        Psychol Neuropsychiatr Vieil. 2006; 4: 215-225
        • Higgins JP
        • Altman DG
        • Gøtzsche PC
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Guyatt G
        • Oxman AD
        • Akl EA
        • et al.
        GRADE guidelines: 1. Introduction-GRADE evidence profiles and summary of findings tables.
        J Clin Epidemiol. 2011; 64: 383-394
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Routledge, New York, NY1988
        • Higgins JPT
        • Thompson SG
        • Deeks JJ
        • Altman DG.
        Measuring inconsistency in meta-analyses.
        BMJ Br Med J. 2003; 327: 557-560
        • Egger M
        • Davey Smith G
        • Schneider M
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • Wrightson JG
        • Schäfer L
        • Smeeton NJ.
        Dual-task prioritization during overground and treadmill walking in healthy adults.
        Gait Posture. 2020; 75: 109-114
        • Wollesen B
        • Rudnik S
        • Gulberti A
        • Cordes T
        • Gerloff C
        • Poetter-Nerger M.
        A feasibility study of dual-task strategy training to improve gait performance in patients with Parkinson's disease.
        Sci Rep. 2021; 11: 12416
        • Barboza TV
        • Weizemann C
        • Carvalho AR.
        Causal relationship between spatiotemporal parameters of walking and the locomotor rehabilitation index in healthy people.
        Gait Posture. 2021; 90: 320-325
        • Çekok K
        • Kahraman T
        • Duran G
        • et al.
        Timed up and go test with a cognitive task: correlations with neuropsychological measures in people with Parkinson's disease.
        Cureus. 2020; 12: e10604
        • Vlagsma TT
        • Koerts J
        • Tucha O
        • et al.
        Mental slowness in patients with Parkinson's disease: associations with cognitive functions?.
        J Clin Exp Neuropsychol. 2016; 38: 844-852
        • Arbuthnott K
        • Frank J.
        Trail making test, part B as a measure of executive control: validation using a set-switching paradigm.
        J Clin Exp Neuropsychol. 2000; 22: 518-528
        • von Bastian CC
        • Belleville S
        • Udale RC
        • et al.
        Mechanisms underlying training-induced cognitive change.
        Nat Rev Psychol. 2022; 1: 30-41
        • Kortte KB
        • Horner MD
        • Windham WK.
        The trail making test, part B: cognitive flexibility or ability to maintain set?.
        Appl Neuropsychol. 2002; 9: 106-109
        • Zheng Y
        • Meng Z
        • Zhi X
        • Liang Z.
        Dual-task training to improve cognitive impairment and walking function in Parkinson's disease patients: a brief review.
        Sports Med Health Sci. 2021; 3: 202-206
        • Wang RY
        • Huang YC
        • Zhou JH
        • Cheng SJ
        • Yang YR.
        Effects of exergame-based dual-task training on executive function and dual-task performance in community-dwelling older people: a randomized-controlled trial.
        Games Health J. 2021; 10: 347-354
        • Lord S
        • Galna B
        • Coleman S
        • Yarnall A
        • Burn D
        • Rochester L.
        Cognition and gait show a selective pattern of association dominated by phenotype in incident Parkinson's disease.
        Front Aging Neurosci. 2014; 6: 249
        • Zak M
        • Krupnik S
        • Brola W
        • et al.
        Functional capacity and dual-task cost in the institutionalized older adults, both affected and unaffected by mild cognitive impairment.
        Eur Rev Aging Phys Act. 2021; 18: 16
        • Johansson H
        • Ekman U
        • Rennie L
        • Peterson DS
        • Leavy B
        • Franzén E.
        Dual-task effects during a motor-cognitive task in Parkinson's disease: patterns of prioritization and the influence of cognitive status.
        Neurorehabil Neural Repair. 2021; 35: 356-366
        • Strouwen C
        • Molenaar EALM
        • Münks L
        • et al.
        Determinants of dual-task training effect size in Parkinson disease: who will benefit most?.
        J Neurol Phys Ther. 2019; 43: 3-11