The effect of divided attention on gait stability following concussion. Rehabilitation of divided attention after severe traumatic brain injury: A randomised trial Balance performance with a cognitive task: a dual-task testing paradigm. Impact of the combination of cognitive and balance training on gait, fear and risk of falling and quality of life in seniors with mild cognitive impairment. Prevalence of neurocognitive and balance deficits in collegiate aged football players without clinically diagnosed concussion. A Randomized Trial to Measure the Impact of a Community-Based Cognitive Training Intervention on Balance and Gait in Cognitively Intact Black Older Adults Impact of Cognitive Training on Balance and Gait in Older Adults. Effects of concussion on attention and executive function in adolescents. Identifying neurocognitive deficits in adolescents following concussion. Evaluation of Neuropsychological Domain Scores and Postural Stability Following Cerebral Concussion in Sports Walking and talking therapy: improving cognitive-motor dual-tasking in neurological illness. Spared Primary Motor Cortex and The Presence of MEP in Cerebral Palsy Dictate the Responsiveness to tDCS during Gait Training Associations among self-reported balance problems, post-concussion symptoms and performance-based tests: a longitudinal follow-up study Training-related changes in dual-task walking performance of elderly persons with balance impairment: a double-blind, randomized controlled trial. Adding Vision to Concussion Testing: A Prospective Study of Sideline Testing in Youth and Collegiate Athletes Use of visual feedback in retraining balance following acute stroke. Balance and cognitive performance during a dual-task: preliminary implications for use in concussion assessment.
BACKGROUND The need to identify functional impairment following a brain injury is critical to prevent re-injury during the period of recovery . While many neuropsychological tests have been developed to assess cognitive performance , relatively little information on gait and dynamic stability is available on motor task performance for young adults following concussion . This study was performed to investigate the effect of divided attention following concussion on various gait variables . It was hypothesized that , when compared to uninjured controls , concussed subjects would demonstrate deficits in maintenance of dynamic stability . METHODS Ten subjects with Grade 2 concussion completed testing within 48 h of injury as well as 10 age- , height- , weight- , and activity-matched controls . The gait protocol consisted of level walking under two conditions : ( 1 ) undivided attention ( single-task ) and ( 2 ) while simultaneously completing simple mental tasks ( dual-task ) . Whole-body motion data were collected using a six-camera motion analysis system . A 13-segment biomechanical model was used to compute whole body center of mass motion and velocity . FINDINGS Walking with a concurrent cognitive task result ed in significant changes in gait and center of mass measurements for both groups . Concussed subjects were found to be able to conservatively adjust their whole body center of mass motion to maintain dynamic stability while walking without divided attention . However , while walking with divided attention , subjects with concussion demonstrated a significantly greater medio-lateral center of mass sway . INTERPRETATION These data suggest that the ability to control and maintain stability in the frontal plane during walking is diminished under divided attention in individuals following a concussion Patients with severe traumatic brain injury ( TBI ) frequently suffer from a difficulty in dealing with two tasks simultaneously . However , there has been little research on the rehabilitation of divided attention . The objective of the present study was to assess the effectiveness of a rehabilitation programme for divided attention after severe TBI . Twelve patients at a subacute/chronic stage after a severe TBI were included . A r and omised AB vs. BA cross-over design was used . Training lasted six weeks , with four one-hour sessions per week . It was compared to a non-specific ( control ) cognitive training . During experimental treatment , patients were trained to perform two concurrent tasks simultaneously . Each one of the two tasks was first trained as a single task , then both tasks were given simultaneously . A progressive hierarchical order of difficulty was used , by progressively increasing task difficulty following each patient 's individual improvement . Patients were r and omised in two groups : one starting with dual-task training , the other with control training . Outcome measures included target dual-task measures , executive and working memory tasks , non-target tasks , and the Rating Scale of Attentional Behaviour addressing attentional problems in everyday life . Assessment was not blind to treatment condition . A significant training-related effect was found on dual-task measures and on the divided attention item of the Rating Scale of Attentional Behaviour . There was only little effect on executive measures , and no significant effect on non-target measures . These results suggest that training had specific effects on divided attention and helped patients to deal more rapidly and more accurately with dual-task situations PURPOSE Athletic performance dem and s simultaneous use of cognitive and postural control capabilities . Decrements to both systems have been observed following concussion . This study evaluated a dual-task methodology to establish the tenability of using this testing model in concussed athletes . METHODS Nonconcussed subjects were assessed over 2 d. Subjects were introduced to the task-switching cognitive assessment test and a NeuroCom Smart Balance Master postural control assessment protocol on day 1 . In the following session , subjects were evaluated on  postural control and cognitive function tests independently ( single task ) , and then concurrently ( dual task ) . RESULTS Significant improvements were seen in three of the four balance conditions and in three of the four reaction times when the cognitive and balance task were performed simultaneously ( P<0.05 ) . No significant balance by cognitive task interaction was revealed ( P>0.05 ) ; however , significant differences existed in reaction time based on stimulus position and increasing balance dem and s ( P<0.05 ) . CONCLUSION Combining the cognitive and balance assessment s result ed in healthy subjects showing improved performance when compared with individual task performance . The dual-task methodology brought about systematic changes to reaction time in relation to increasing balance dem and s. The ability of this protocol to detect changes in postural control or cognitive function following concussive injury requires further study AIM To investigate the effect of specific cognitive training with CogniPlus and balance training , affecting cognitive functioning , gait speed , risk and fear of falling , and quality of life in an elderly cohort with mild cognitive impairment . METHODS The research sample was composed of 80 older adults with a mild cognitive deficit ( mean age 67.07 years ) divided into the experimental group ( n = 40 ) and control group ( n = 40 ) . This was a r and omized , controlled trial . The experimental group carried out selected exercises from the CogniPlus program combined with balance training . Patients participated in 20 sessions twice per week in an outpatient clinic . Both groups completed 30 min of balance training daily for 10 weeks . Cognitive functions were evaluated by the Mini-Mental State Examination . The fear of falling was assessed by Falls Efficacy Scale-I. The static and dynamic aspects of balance were assessed by the Tinetti test and functional stretching . Gait speed was assessed by four forms of the Timed Up & Go test . Quality of life was investigated according to Spitzer . RESULTS The two groups showed significant differences recorded after training in the Mini-Mental State Examination , Up and Go test with dual tasking , balance by Tinetti test and the quality of life in favor of the experimental group ( P < 0.03 - 0.0001 ) . There were no significant differences found between the groups in the assessment of fear of falling and other monitored parameters . CONCLUSIONS The combination of selected exercises from the CogniPlus program with balance training contributed to achieving better results than balance training alone for elderly people with mild cognitive impairment . Geriatr Gerontol Int 2016 ; 16 : 1043 - 1050 STUDY DESIGN Prospect i ve cohort . OBJECTIVES To identify the prevalence of neurocognitive and balance deficits in collegiate football players 48 hours following competition . BACKGROUND Neurocognitive testing , balance assessment s , and subjective report of symptoms are a commonly used test battery in examining athletes when concussion is suspected . Previous literature suggests many concussions go unreported . Little research exists examining the prevalence of neurocognitive or balance deficits in athletes who do not report concussion-like symptoms to a health care provider . METHODS Forty-five Division IA collegiate football players participated in this study . Preseason baseline scores using the  Balance Error Scoring System , the Immediate Post-Concussion Assessment and Cognitive Testing , and the Postconcussion Symptom Scale  were compared to posttest results obtained 48 hours following a game . Prevalence of symptoms was analyzed and reported . RESULTS Thirty-two ( 71 % ) of the 45 athletes tested demonstrated at least 1 deficit in either the Postconcussion Symptom Scale , Balance Error Scoring System , or at least 1 composite score of the Immediate Post-Concussion Assessment and Cognitive Testing . Nineteen of the 32 subjects demonstrated a change in 2 or more categories of neurocognitive and balance function . CONCLUSION In a cohort of football players tested 48 hours following their last game of the season , who did not seek medical attention related to a concussion , a significant number demonstrated limitations in neurocognitive and balance performance , suggesting that further research may need to be performed to improve recognition of an athlete 's deficits and to improve the ability to assess concussion . LEVEL OF EVIDENCE Differential diagnosis/symptom prevalence , level 3b Introduction . Fall prevention is important for maintaining mobility and independence into old age . Approaches for reducing falls include exercise , tai chi , and home modifications ; however , causes of falling are multifactorial and include not just physical but cognitive factors . Cognitive decline occurs with age , but older adults with the greatest declines in executive function experience more falls . The purpose of this study was twofold : to demonstrate the feasibility of a community-based cognitive training program for cognitively intact Black older adults and to analyze its impact on gait and balance in this population . Method . This pilot study used a pretest/posttest r and omized trial design with assignment to an intervention or control group . Participants assigned to the intervention completed a computer-based cognitive training class that met 2 days a week for 60 min over 10 weeks . Classes were held at senior/community centers . Primary outcomes included balance as measured by the Berg Balance Scale ( BBS ) , 10-meter gait speed , and 10-meter gait speed under visuospatial dual-task condition . All measures were assessed at baseline and immediately post-intervention . Results . Participants were community-dwelling Black adults with a mean age of 72.5 and history of falls ( N = 45 ) . Compared to controls , intervention participants experienced statistically significant improvements in BBS and gait speed . Mean performance on distracted gait speed also improved more for intervention participants compared to controls . Conclusion . Findings from this pilot r and omized trial demonstrate the feasibility of a community-based cognitive training intervention . They provide initial evidence that cognitive training may be an efficacious approach toward improving balance and gait in older adults known to have a history of falls OBJECTIVES Cognitive processing plays an important role in balance and gait and is a contributing factor to falls in older adults . This relationship may be explained by the fact that higher order cognitive functions such as executive functions are called upon while walking . The purpose of this study was to examine whether a cognitive training intervention leads to significant improvements on measures of balance and gait . METHOD This r and omized trial tested whether cognitive training over 10 weeks improves balance and gait  in older adults . Participants were r and omly assigned to a computer-based cognitive training intervention or measurement-only control . Outcomes included Timed Up and Go ( TUG ) , gait speed , and gait speed with a cognitive distraction . Data were analyzed using analysis of covariance models with change scores . RESULTS Participants ' ( N = 51 ) average age was 82.7 for those r and omized to intervention and 81.1 for those r and omized to control . After 10 weeks , intervention group participants performed significantly better than controls on the TUG . When the cohort was limited to those categorized as slow walkers ( baseline 10-m walk ≥ 9 s ) , intervention participants performed significantly better than controls on TUG and distracted walking . DISCUSSION Cognitive training slows degradation of balance and improves gait while distracted , rendering it a promising approach to falls prevention BACKGROUND Head trauma in adolescents has been linked with deficits in attention and executive function that can compromise the performance of everyday tasks . Although previous research has examined this issue using computerized neuropsychological testing , little work has been done using laboratory-based measurements of attention and executive function in this population . A longitudinal analysis of recovery patterns of these measures among adolescents is central to underst and ing the effects of concussions across the age spectrum . PURPOSE This study prospect ively and longitudinally examined laboratory-based measures of attention and executive function in concussed adolescents sequentially during a 2-month period after injury . METHODS Two measures of attention and executive function , the Attentional Network Test and the Task-Switching Test  , were administered to 20 concussed adolescents within 72 h postinjury as well as at 1 wk , 2 wk , 1 month , and 2 months postinjury . Twenty healthy , matched control subjects were similarly assessed at the same time intervals . Data were analyzed by two-way , mixed-effects ANOVA to determine the effect of group and time on the dependent variables . RESULTS Compared with control subjects , the concussed group exhibited a significantly greater switch cost on the Task-Switching Test ( P = 0.038 , mean difference value = 38 ms ) and a significantly greater reaction time for the Attentional Network Test conflict effect component ( P = 0.015 , mean difference value = 34 ms ) for up to 2 months after injury . CONCLUSIONS Concussed adolescents have difficulty recovering executive function after injury and may require extended recuperation time before full recovery is achieved . Evaluations focusing on attention and executive function can be useful additions in the assessment and follow-up after head injury OBJECTIVES This study of concussed adolescents sought to determine if a computer-based neurocognitive assessment ( Immediate Postconcussion Assessment and Cognitive Test [ ImPACT ] ) performed on patients who present to the emergency department ( ED ) immediately following head injury would correlate with assessment s performed 3 to 10 days postinjury and if ED neurocognitive testing would detect differences in concussion severity that clinical grading scales could not . METHODS A prospect i ve cohort sample of patients 11 to 17 years of age presenting to the ED within 12 hours of a head injury were evaluated using two traditional concussion grading scales and neurocognitive testing .  ED neurocognitive scores were compared to follow-up scores obtained at least 3 days postinjury . Postconcussive symptoms , outcomes , and complications were assessed via telephone follow-up for all subjects . RESULTS Sixty patients completed phone follow-up . Thirty-six patients ( 60 % ) completed follow-up testing a median of 6 days postinjury . Traditional concussion grading did not correlate with neurocognitive deficits detected in the ED or at follow-up . For the neurocognitive domains of verbal memory , processing speed , and reaction time , there was a significant correlation between ED and follow-up scores trending toward clinical improvement . By 2 weeks postinjury , 23 patients ( 41 % ) had not returned to normal activity . At 6 weeks , six patients ( 10 % ) still had not returned to normal activity . CONCLUSIONS Immediate assessment in the ED can predict neurocognitive deficits seen in follow-up and may be potentially useful to individualize management or test therapeutic interventions . Neurocognitive assessment in the ED detected deficits that clinical grading could not and correlated with deficits at follow-up Context With increasing knowledge and research about concussion , there have been few objective studies that have used neuropsychological domain scores and postural stability to assess concussion . Objective To evaluate the recovery curve of athletes who incur sport-related concussion from repeated serial testing of neuropsychological and posturography testing . Design A prospect i ve epidemiological model was used for the course of the study . Setting Division I intercollegiate athletics . Participants Athletes participating in football , soccer , basketball , softball , and cheerleading . Main Outcome Measures  Neuropsychological scores and posturography measures  were obtained preseason and serially at day 1 , day 2 , day 3 , and day 10 postconcussion .  Control participants  were tested at the same intervals .  Neuropsychological scores were converted to st and ards score and then into domains of attention , learning , speed of information processing , concentration , memory , and verbal fluency . Analysis of covariance with the baseline test as the covariate was used to analyze the data with univariate post hoc tests performed . Results Significant group differences were found for self reported symptoms ( P = 0.001 ) , speed of information processing ( P = 0.005 ) , mean stability ( P = 0.002 ) , and vestibular function ( P = 0.003 ) between injured and control participants . A group , by day , planned comparison found that speed of information processing and composite balance measures demonstrated significant differences through day 10 postinjury , while symptoms and the vestibular ratio remained significant only through day 3 . Conclusions The concussion recovery curve demonstrated short-term neuropsychological and posturography deficits following injury . A comprehensive approach to concussion management should be used to assess the injury and make return-to-play decisions Using r and omized control trial methodology , we evaluated the effectiveness of a 5-week cognitive-motor dual-tasking training program developed to improve performance of a group of people with dual-tasking difficulties arising from acquired brain injury . Training involved twice-daily practice on exercises involving walking being combined with tasks which increased in cognitive dem and over the course of the intervention . A treatment group ( n = 10 ) was compared with a control group ( n = 9 ) . The primary outcome measure was a task requiring participants to walk and carry out a spoken sentence verification task simultaneously . Secondary outcome measures were measures of dual-tasking involving either two motor tasks or two cognitive tasks . A question naire measure relating to activities of daily living requiring dual-tasking was also completed . Compliance with the training program was good . We found evidence of improvement in performance on the primary outcome measure , but little evidence of generalization to other measures . There was some evidence that participants believed that their dual-tasking performance in everyday life was improved after the intervention . The study was limited in terms of sample size , was not blinded and did not control fully for therapist contact time , but has produced valuable data relating to effect sizes associated with this form of intervention . ( JINS , 2009 , 15 , 112 - 120 . ) The current priority of investigations involving transcranial direct current stimulation ( tDCS ) and neurorehabilitation is to identify biomarkers associated with the positive results of the interventions such that respondent and non-respondent patients can be identified in the early phases of treatment . The aims were to determine whether : ( 1 ) present motor evoked potential ( MEP ) ; and ( 2 ) injuries involving the primary motor cortex , are associated with tDCS-enhancement in functional outcome following gait training in children with cerebral palsy ( CP ) . We review ed the data from our parallel , r and omized , sham-controlled , double-blind studies . Fifty-six children with spastic CP received gait training ( either treadmill training or virtual reality training ) and tDCS ( active or sham ) . Univariate and multivariate logistic regression analyses were employed to identify clinical , neurophysiologic and neuroanatomic predictors associated with the responsiveness to treatment with tDCS .  MEP presence during the initial evaluation and the subcortical injury were associated with positive effects in the functional results . The logistic regression revealed that present MEP was a significant predictor for the six-minute walk test ( 6MWT ; p = 0.003 ) and gait speed ( p = 0.028 ) , whereas the subcortical injury was a significant predictor of gait kinematics ( p = 0.013 ) and gross motor function ( p = 0.021 ) . In this preliminary study involving children with CP , two important prediction factors of good responses to anodal tDCS combined with gait training were identified . Apparently , MEP ( integrity of the corticospinal tract ) and subcortical location of the brain injury exerted different influences on aspects related to gait , such as velocity and kinematics Purpose : The main objectives of this study were to describe long-term self-reported balance problems  and to explore their associations with post-concussion symptoms and performance-based tests . Method : Prospect i ve study of patients with mild traumatic brain injury ( MTBI ) .  Self-reported balance problems and post-concussion symptoms were measured with the Rivermead Post-concussion Symptoms Question naire at 1 and 4 years after injury . Performance-based tests were performed 4 years after injury and included  posturography , the Dynamic Gait Index ( DGI ) , walking speed tests , and the six-minute walk test . Results : Self-reported balance problems were reported in 31 % of patients 4 years after injury and correlated significantly with post-concussion symptoms . The correlations with performance-based tests varied from ρ = 0.18 to ρ = 0.70 and were strongest for the maximum walking speed test ( ρ = 0.70 ) and a dual-task test ( ρ = 0.43 ) . The DGI had a considerable ceiling effect . Conclusions : Balance problems were long-term consequences of MTBI in one third of this study sample . Self-reported balance problems correlated with post-concussion symptoms and some of the performance-based tests . Future research needs to develop and evaluate appropriate rehabilitation strategies that also address the balance problems . Implication s for Rehabilitation Balance problems may persist several years after a mild traumatic brain injury . We need to develop and evaluate appropriate rehabilitation strategies that also address the balance problems The purpose of this study was to compare the efficiency of three different balance training strategies in an effort to underst and the mechanisms underlying training-related changes in dual-task balance performance of older adults with balance impairment . Elderly individuals with balance impairment , age 65 and older , were r and omly assigned to one of three individualized training programs : single-task ( ST ) balance training ; dual-task training with fixed-priority ( FP ) instruction ; and dual-task training with variable-priority ( VP ) instruction .  Balance control during gait , under practice d and novel conditions , was assessed by calculating the center of mass and ankle joint center inclination angles in the frontal plane . A smaller angle indicated better balance performance . Other outcomes included gait velocity , stride length , verbal reaction time , and rate of response . All measures were collected at baseline and the end of the 4-week training . Results indicated that all training strategies were equally effective ( P>.05 ) at improving balance performance ( smaller inclination angle ) under single-task context s. However , the VP training strategy was more effective ( P=.04 ) in improving both balance and cognitive performance under dual-task conditions than either the ST or the FP training strategies . Improved dual-task processing skills did not transfer to a novel dual-task condition . Results support Kramer et al. 's proposal that VP training improves both single-task automatization and the development of task-coordination skills Background : Sports-related concussion commonly affects the visual pathways . Current sideline protocol s test cognition and balance but do not include assessment s of visual performance . We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels . Methods : Participants in this prospect i ve study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Isl and University . Athletes underwent preseason baseline assessment s using : 1 ) the King – Devick ( K-D ) test , a < 2-minute visual performance measure of rapid number naming , 2 ) the St and ardized Assessment of Concussion ( SAC ) , a test of cognition , and 3 ) a timed t and em gait test of balance .  The SAC and timed t and em gait are components of the currently used Sport Concussion Assessment Tool , 3rd Edition ( SCAT3 and Child-SCAT3 ) . In the event of a concussion during the athletic season , injured athletes were retested on the sideline/rink-side . Nonconcussed athletes were also assessed as control participants under the same testing conditions . Results : Among 243 youth ( mean age 11 ± 3 years , range 5–17 ) and 89 collegiate athletes ( age 20 ± 1 years , range 18–23 )  , baseline time scores for the K-D test were lower ( better ) with increasing participant age ( P < 0.001 , linear regression models ) . Among 12 athletes who sustained concussions during their athletic season , K-D scores worsened from baseline by an average of 5.2 seconds ; improvement by 6.4 seconds was noted for the nonconcussed controls ( n = 14 ) . The  vision-based K-D test  showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury ( receiver operating characteristic [ ROC ] curve areas from logistic regression models , accounting for age = 0.92 for K-D , 0.87 for timed t and em gait , and 0.68 for SAC ; P = 0.0004 for comparison of ROC curve areas ) . Conclusions : Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment . This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision BACKGROUND AND PURPOSE Visual feedback related to weight distribution and center-of-pressure positioning has been shown to be effective in increasing stance symmetry following stroke , although it is not clear whether functional balance ability also improves . This study compared the relative effectiveness of visual feedback training of center-of-gravity ( CoG ) positioning with conventional physical therapy following acute stroke . SUBJECTS Forty-six people who had strokes within 80 days before the study , result ing in unilateral hemiparesis , and who were in need of balance retraining participated . METHODS AND MATERIAL S Initially , subjects were r and omly assigned to visual feedback or conventional physical therapy groups for balance retraining until 16 subjects per group were recruited . The next 14 subjects were assigned to a control group . All subjects received physical therapy and occupational therapy ( regular therapy ) 2 hours a day , and subjects in the 2 experimental groups received additional balance training 30 minutes a day until discharge . The visual feedback group received information about their CoG position as they shifted their weight during various activities . The conventional therapy group received verbal and tactile cues to encourage symmetrical stance and weight shifting . Static ( postural sway ) and activity-based measures of balance ( Berg Balance Scale , gait speed , and the Timed " Up & Go " Test ) were contrasted across the 3 groups at baseline , at discharge , and at 1 month following discharge using an analysis of variance for repeated measures . RESULTS All groups demonstrated marked improvement over time for all measures of balance ability , with the greatest improvements occurring in the period from baseline to discharge . No between-group differences were detected in any of the outcome measures . CONCLUSION AND DISCUSSION Visual feedback or conventional balance training in addition to regular therapy affords no added benefit when offered in the early stages of rehabilitation following stroke OBJECTIVES To determine the reliability and effects of a dual-task paradigm on  balance and cognitive function  compared to a single-task paradigm . DESIGN Repeated measures . METHODS Healthy participants ( n=23 ) completed a variation of the Sensory Organization Test and the incongruent Stroop test individually ( single-task ) and concurrently ( dual-task ) during two testing sessions . RESULTS The Sensory Organization Test and incongruent Stroop test had moderate to high reliability ( 1.00>ICC2,k>0.60 ) under the dual-task conditions . Reaction time was significantly longer ( t21=-2.54 , p=0.019 ) under the dual-task conditions , while balance scores under one of the four conditions of the Sensory Organization Test ( sway floor/fixed wall ) were statistically better ( t22=-3.03 , p=0.006 ) under the dual-task conditions . However , this difference in balance scores may not be clinical ly meaningful . CONCLUSIONS These findings illustrate that the Sensory Organization Test and incongruent Stroop task can be reliably incorporated into a dual-task assessment paradigm . The slowed reaction time under the dual-task paradigm indicates that the dual-task provided an additional cost to cognitive function . Dual-task concussion assessment paradigms involving these two tasks are psychometrically appropriate as well as more representative of actual sporting situations . However , more research should be conducted in a concussed population to further vali date this cl aim
Response times are greater , gait strategies are less efficient , and postural control deficits are greater in concussed participants compared with healthy controls both immediately and for some period following concussive injury , specifically under divided attention conditions .
Dual task assessment s in some cases were more reliable than single task assessment s and may be better able to detect lingering effects following concussion .
This article is a systematic review of the literature on divided attention assessment inclusive of a cognitive and motor task ( balance or gait ) for use in concussion management .