This paper presents a protocol specifically for dual motor task gait analysis in stroke patients with motor control deficits.
Eighteen stroke patients were recruited for this study involving the evaluation of cognition and walking ability and multitask gait analysis. Multitask gait analysis consisted of a single walking task (Task 0), a simple motor dual-task (water-holding, Task 1), and a complex motor dual-task (crossing obstacles, Task 2). The task of crossing obstacles was considered to be equivalent to the combination of a simple walking task and a complex motor task as it involved more nervous system, skeletal movement, and cognitive resources. To eliminate heterogeneity in the results of the gait analysis of the stroke patients, the dual-task gait cost values were calculated for various kinematic parameters. The major differences were observed in the proximal joint angles, especially in the angles of the trunk, pelvis, and hip joints, which were significantly larger in the dual motor tasks than in the single walking task. This research protocol aims to provide a basis for the clinical diagnosis of gait function and an in-depth study of motor control in stroke patients with motor control deficits through the analyses of dual-motor walking tasks.
The restoration of independent walking function is one of the requisites for the participation of post-stroke patients in community life1. The recovery of walking ability requires not only the interaction of the perception and cognitive systems, but also motor control2,3,4. Furthermore, in real community life, people require higher abilities such as performing two or more tasks at the same time (e.g., walking while holding objects or crossing obstacles). Therefore, studies have begun to focus on the interference of dual-tasks in gait performance5,6. Previous dual-task studies were mostly targeted to elderly and cognitively impaired patients owing to the difficulty in motor performance and heterogeneity in stroke patients; the gait function in stroke patients was mostly evaluated by a single walking task7,8,9. However, further research on dual-task gait analysis, especially motor dual-tasks related to motor control, is required.
This study introduces a methodology for dual motor task gait analysis and evaluation. This protocol not only includes clinical assessment of the walking ability in stroke patients, but also focuses on two dual-motor tasks: the holding-water-and-walking task (a simple dual motor task) and the crossing-obstacle walking task (a complex dual motor task). The aim of this study was to explore the effects of dual motor tasks on the gait of stroke patients and to employ the dual-task gait cost (DTC) values10 of dual-task parameters (the difference between a single task and dual-task) to exclude the heterogeneity among stroke patients. The design of the experimental tasks facilitated an in-depth discussion of the motor control function of stroke patients, which provided new ideas for the clinical diagnosis and evaluation of the gait function of stroke patients.
NOTE: The clinical study was approved by the Medical Ethics Association of the Fifth Affiliated Hospital of Guangzhou Medical University (NO. KY01-2019-02-27) and has been registered at the China Clinical Trial Registration Center (No. ChiCTR1800017487 and entitled, "The multiple modal tasks on gait control and motor cognition after stroke").
1. Recruitment
2. Clinical evaluation
3. 3D gait analysis
4. Data processing and analysis
5. Data extraction and statistical analysis of interest
Eighteen patients with hemiplegia after stroke were recruited in this study. The average age of the participants was 51.61 ± 12.97 years; all were males. The proportion of left and right hemiplegia was 10/8; the average Brunnstrom stage was 4.50 ± 0.76. The average of MMSE and MoCA were 26.56 ± 1.67 and 20.06 ± 2.27, respectively. Other demographic characteristics (including stroke type and time of onset) are shown in Table 1. For the original data of gait dual-tasks (Task 1 and Task 2), there was no statistical difference in the spatiotemporal parameters (Table 2). However, in the joint angle parameters, the bilateral trunk rotation (transversal plane) was larger in Task 2 than in Task 1 (left side: Task 1, 18.40 ± 5.76 vs. Task 2, 26.35 ± 14.92, P = 0.004; right side: Task 1, 18.39 ± 7.04 vs. Task 2, 24.08 ± 18.18, P = 0.001). Bilateral pelvic rotation (transversal plane) was larger in Task 2 than in Task 1 (left side: Task 1, 20.71 ± 7.97 vs. Task 2, 21.31 ± 6.96, P = 0.024; right side: Task 1, 27.56 ± 9.71 vs. Task 2, 29.264 ± 11.17, P = 0.006). The differences were statistically significant (Table 3).
For the DTC values of gait dual-tasks (Task 1 and Task 2), the bilateral trunk obliquity (frontal plane) was higher in Task 2 than in Task 1 (left side: Task 1, 2.60 ± 36.38 vs. Task 2, -23.4 ± 40.62, P = 0.006; right side: Task 1, -10.82 ± 47.58 vs. Task 2, -11.42 ± 30.10, P = 0.013). The bilateral pelvic rotation (transversal plane) was higher in Task 2 than in Task 1 (left side: Task 1, -2.75 ± 36.20 vs. Task 2, -23 ± 40.36, P = 0.011; right side: Task 1, 1.66 ± 43.72 vs. Task 2, -31.89 ± 58.50, P = 0.006). All differences were statistically significant (Table 4 and Figure 2). At the same time, the right Cadence was significantly decreased in Task 2 relative to that in Task 1 (right side: Task 1, 18.40 ± 5.76 vs. Task 2, 26.35 ± 14.92, P = 0.044), and the right GPS was significantly decreased in Task 2 relative to that in Task 1 (right side: Task 1, 20.71 ± 4.87 vs. Task 2, 24.24 ± 10.33, P = 0.047) (Table 5 and Figure 3).
Figure 1: The gait analysis settings are based on the Davis protocol. Please click here to view a larger version of this figure.
Figure 2: Comparing the DTC values of trunk and joint angle parameters of the simple motor dual-task (Task 1) and complex motor dual-task (Task 2). (A) Trunk obliquity (frontal plane); (B) trunk rotation (transversal plane); (C) pelvic rotation (transversal plane). Abbreviation: DTC = dual-task gait cost. Please click here to view a larger version of this figure.
Figure 3: Comparing the DTC values of spatiotemporary parameters of the simple motor dual-task (Task 1) and the complex motor dual-task (Task 2). Percentages of (A) stance phase and (B) swing phase are shown for one gait cycle. Percentages of (C) single stance phase and (D) double stance phase are shown for one gait cycle. (E) The cadence and (F) GPS index are shown. Abbreviations: DTC = dual-task gait cost; GPS = Gait Performance Score. Please click here to view a larger version of this figure.
Subject | Sex | Age (years) | Hemorrhage/infarct | Hemiplegic side | Stroke onset (months) | Brunnstrom-stage (LE) | MMSE | MoCA | 10MWT (customized speed) | 10MWT (fast speed) | TUGT (s) |
001 | male | 30 | Hemorrhage | right | 29 | 5 | 25 | 18 | 0.52 | 0.62 | 26 |
002 | male | 59 | Infarct | left | 26 | 6 | 30 | 23 | 0.43 | 0.52 | 36 |
003 | male | 27 | Infarct | left | 26 | 5 | 24 | 19 | 0.46 | 0.48 | 48 |
004 | male | 54 | Hemorrhage | right | 23 | 5 | 26 | 18 | 0.56 | 0.61 | 58 |
005 | male | 63 | Infarct | left | 23 | 4 | 29 | 23 | 0.62 | 0.72 | 28 |
006 | male | 45 | Infarct | left | 23 | 5 | 25 | 19 | 0.56 | 0.63 | 33 |
007 | male | 67 | Hemorrhage | left | 22 | 4 | 28 | 17 | 0.59 | 0.67 | 45 |
008 | male | 42 | Infarct | left | 21 | 3 | 29 | 23 | 0.67 | 0.73 | 27 |
009 | male | 38 | Infarct | right | 18 | 4 | 28 | 20 | 0.52 | 0.67 | 26 |
010 | male | 70 | Infarct | left | 31 | 4 | 26 | 23 | 0.64 | 0.68 | 30 |
011 | male | 49 | Hemorrhage | left | 17 | 4 | 24 | 20 | 0.46 | 0.53 | 45 |
012 | male | 42 | Infarct | left | 19 | 3 | 27 | 16 | 0.43 | 0.56 | 49 |
013 | male | 45 | Infarct | right | 26 | 5 | 26 | 24 | 0.56 | 0.74 | 29 |
014 | male | 45 | Hemorrhage | right | 28 | 4 | 26 | 19 | 0.64 | 0.73 | 27 |
015 | male | 54 | Infarct | right | 18 | 5 | 25 | 21 | 0.52 | 0.65 | 33 |
016 | male | 68 | Infarct | right | 14 | 5 | 27 | 20 | 0.57 | 0.59 | 42 |
017 | male | 69 | Infarct | left | 15 | 5 | 26 | 18 | 0.52 | 0.63 | 38 |
018 | male | 62 | Infarct | right | 24 | 5 | 27 | 20 | 0.61 | 0.72 | 31 |
mean±SD | 51.61±12.97 | NA | NA | 22.39±4.70 | 4.50±0.76 | 26.56±1.67 | 20.06±2.27 | 0.55±0.07 | 0.64±0.08 | 36.17±9.29 |
Table 1: Basic characteristics of study subjects. Values are presented as a number or mean ± standard deviation. Abbreviations: MMSE = Mini-Mental State Examination; MoCA = Montreal Cognitive Assessment; 10MWT = 10-meter walk test; TUGT = timed up and go test; SD = standard deviation; LE = lower extremity; s = second.
Left side | Right side | |||||||
Task 1 | Task 2 | Difference | P value | Task 1 | Task 2 | Difference | P value | |
Stance phase (%) | 20.71±7.97 | 21.31±6.96 | 0.60±10.58 | 0.916 | 18.02±4.86 | 20.66±7.41 | 2.64±8.86 | 0.254 |
Swing phase (%) | 27.56±9.71 | 29.26±11.17 | 1.70±14.80 | 0.285 | 23.68±6.74 | 29.88±12.19 | 6.20±13.93 | 0.916 |
Single stance (%) | 26.91±5.41 | 31.09±11.67 | 4.18±12.86 | 0.519 | 31.16±9.27 | 27.80±10.67 | -3.36±14.13 | 0.583 |
Double stance (%) | 24.72±7.10 | 31.31±5.99 | 6.59±9.29 | 0.291 | 37.55±17.79 | 44.10±12.60 | 6.55±21.80 | 0.369 |
Cadence (steps/min) | 18.40±5.76 | 26.35±14.92 | 7.95±15.99 | 0.521 | 18.39±7.04 | 24.08±18.18 | 5.79±19.50 | 0.720 |
GPS (scores) | 17.91±7.24 | 23.09±9.49 | 5.18±11.94 | 0.580 | 20.71±4.87 | 24.24±10.33 | 3.53±11.42 | 0.058 |
Table 2: Differences in spatiotemporary parameters of the simple motor dual-task (Task 1) and complex motor dual-task (Task 2). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold. Abbreviations: GPS = Gait Performance Score; min = minute.
Left side | Right side | |||||||
Task 1 | Task 2 | Difference | P value | Task 1 | Task 2 | Difference | P value | |
Trunk Obliquity (Frontal plane) | 27.86±7.45 | 24.63±4.08 | -3.23±8.49 | 0.263 | 37.91±4.76 | 48.89±7.56 | 10.98±8.93 | 0.114 |
Trunk Tilt (Sagittal plane) | 31.43±12.69 | 34.25±12.69 | 2.82±17.95 | 0.238 | 24.64±7.53 | 29.85±16.93 | 5.21±18.53 | 0.582 |
Trunk Rotation (Transversal plane) | 18.40±5.76 | 26.35±14.92 | 7.95±15.99 | 0.004 | 18.39±7.04 | 24.08±18.18 | 5.69±19.50 | 0.001 |
Plevic Obliquity (Frontal plane) | 16.99±6.07 | 25.05±15.43 | 8.06±16.58 | 0.277 | 20.66±7.41 | 18.02±4.86 | -2.64±8.86 | 0.937 |
Plevic Tilt (Sagittal plane) | 23.68±6.74 | 29.88±12.19 | 6.20±13.93 | 0.282 | 34.94±18.29 | 39.31±12.86 | 4.37±22.36 | 0.689 |
Plevic Rotation (Transversal plane) | 20.71±7.97 | 21.31±6.96 | 0.60±10.58 | 0.024 | 27.56±9.71 | 29.26±11.17 | 1.70±14.80 | 0.006 |
Hip Ab-Adduction | 20.71±4.87 | 24.24±10.33 | 3.53±11.42 | 0.148 | 17.91±7.24 | 23.09±9.49 | 5.18±11.94 | 0.238 |
Hip Flex-Extension | 37.55±17.79 | 44.10±21.60 | 6.55±27.98 | 0.544 | 13.00±2.59 | 19.87±10.16 | 6.87±10.48 | 0.531 |
Hip Rotation | 27.69±11.17 | 28.27±13.78 | 0.58±17.74 | 0.323 | 31.16±9.27 | 27.80±10.67 | -3.36±14.13 | 0.006 |
Knee Flex-Extension | 26.91±5.41 | 31.09±11.67 | 4.18±12.86 | 0.475 | 23.37±7.75 | 29.16±18.66 | 5.79±20.21 | 0.791 |
Ankle Dors-Plantarflex | 21.75±11.07 | 27.54±13.41 | 5.79±17.39 | 0.213 | 25.87±10.71 | 25.87±11.50 | 0±15.71 | 0.112 |
Table 3: Differences in trunk and joint angle parameters of the simple motor dual-task (Task 1) and complex motor dual-task (Task 2). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold.
Left side | Right side | |||||||
Task 1 | Task 2 | Difference | P value | Task 1 | Task 2 | Difference | P value | |
Trunk Obliquity (Frontal plane) | 2.60±36.38 | -23.4±40.62 | -26.00±54.53 | 0.006 | -10.82±47.58 | -11.42±30.10 | -0.60±56.30 | 0.013 |
Trunk Tilt (Sagittal plane) | 15.34±7.74 | 13.40±8.22 | -1.94±11.29 | 0.260 | 16.28±5.12 | 36.62±5.20 | 20.34±7.30 | 0.489 |
Trunk Rotation (Transversal plane) | -8.15±26.55 | -18.56±29.54 | -10.41±39.72 | 0.004 | 2.75±36.20 | -23.00±40.36 | -25.75±54.22 | 0.001 |
Pelvic Obliquity (Frontal plane) | 15.34±7.74 | 13.40±8.22 | -1.94±11.29 | 0.153 | 62.51±4.53 | 64.40±6.19 | 1.89±7.67 | 0.962 |
Pelvic Tilt (Sagittal plane) | 37.49±6.36 | 37.60±6.19 | 0.11±8.88 | 0.097 | 12.89±6.36 | 14.32±3.79 | 1.43±7.43 | 0.510 |
Pelvic Rotation (Transversal plane) | -2.75±36.20 | -23±40.36 | -20.25±54.22 | 0.011 | 1.66±43.72 | -31.89±58.50 | -30.23±73.03 | 0.006 |
Hip Ab-Adduction | 83.15±7.21 | 78.49±5.91 | -4.66±9.32 | 0.125 | 84.18±8.81 | 92.56±6.51 | 8.38±10.95 | 0.242 |
Hip Flex-Extension | 37.49±6.36 | 37.60±6.19 | 0.11±8.88 | 0.392 | 12.89±6.36 | 14.32±3.79 | 1.43±7.40 | 0.583 |
Hip Rotation | 37.64±6.87 | 36.98±6.21 | -0.66±9.26 | 0.549 | 49.6±8.52 | 56.52±4.52 | 6.92±9.65 | 0.004 |
Knee Flex-Extension | 50.68±4.89 | 67.63±4.87 | 16.95±6.90 | 0.343 | 78.54±7.92 | 57.95±7.16 | -20.59±10.68 | 0.673 |
Ankle Dors-Plantarflex | 27.86±7.45 | 24.63±4.08 | -3.23±8.50 | 0.263 | 37.91±4.76 | 48.89±7.56 | 10.98±8.93 | 0.114 |
Table 4: Differences in dual-task gait cost values of trunk and joint angle parameters of the simple motor dual-task (Task 1) and complex motor dual-task (Task 2). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold.
Left side | Right side | |||||||
Task 1 | Task 2 | Difference | P value | Task 1 | Task 2 | Difference | P value | |
Stance phase (%) | 74.44±31.37 | 79.08±16.36 | 4.64±35.38 | 0.916 | 63.24±7.60 | 36.76±5.84 | -26.48±9.58 | 0.236 |
Swing phase (%) | 35.15±7.74 | 15.34±4.53 | -19.81±8.97 | 0.980 | 63.24±7.61 | 52.28±4.36 | -10.96±8.77 | 0.654 |
Single stance (%) | 62.51±6.19 | 62.40±6.36 | -0.11±8.88 | 0.348 | 37.49±6.19 | 37.60±6.36 | 0.11±8.88 | 0.671 |
Double stance (%) | 37.78±14.71 | 39.19±8.05 | 1.41±16.77 | 0.164 | 37.03±15.55 | 39.19±8.05 | 2.16±17.51 | 0.406 |
Cadence (steps/min) | 2.53±55.72 | 12.13±43.62 | 9.60±70.76 | 0.087 | 18.40±5.76 | 26.35±14.92 | 7.95±15.99 | 0.044 |
GPS (scores) | 11.1±34.86 | 9.65±37.01 | -1.45±50.84 | 0.681 | 20.71±4.87 | 24.24±10.33 | 3.53±11.42 | 0.047 |
Table 5: Differences in dual-task gait cost values of spatiotemporary parameters of the simple motor dual-task (Task 1) and complex motor dual-task (Task 2). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold. Abbreviations: GPS = Gait Performance Score; min = minute.
Supplementary Table 1: Differences in trunk and joint angle parameters of single motor tasks (Task 0), simple motor dual-task (Task 1), and complex motor dual-task (Task 2) (degree). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold. Please click here to download this Table.
Supplementary Table 2: Differences in spatiotemporary parameters of single motor tasks (Task 0), simple motor dual-task (Task 1), and complex motor dual-task (Task 2). Values are presented as a number or mean ± standard deviation. Statistical significance was set as P < 0.05 and marked in bold. Abbreviations: GPS = Gait Performance Score; min = minute. Please click here to download this Table.
This study describes a protocol for the clinical assessment of dual motor task gait analysis in stroke patients with motor control deficits. The design of this protocol was based on two main points. First, most previous studies used a single walking task to assess the gait function of stroke patients, and the related discussions on motor control were inadequate, especially because the principles of complex motor movements were rarely involved22,23. Therefore, in this study, in addition to the single walking task as the baseline, the authors mainly focused on the comparison of two dual-tasks of motor performance and walking, including the task of water-holding (simple motor dual-task) and the task of crossing obstacles (complex motor dual-task)24. The water-holding task was identified as being equivalent to a combination of a simple walking task and a simple motor task.
Because the cross-obstacle walking task involvedmore nervous system, skeletal muscle movement, and cognitive resources in participating in motor control (including motor planning, motor coordination, and motor feedback) than the simple motor dual-task of holding water while walking, it was identified as being equivalent to a combination of a simple walking task and a complex motor task. Thus, the motor control function deficit after stroke could be closely examined based on this experimental task design. Previous dual-task gait analyses in the elderly and in patients with cognitive impairment have reported decreased velocity and cadence in dual-task walking compared with single-task walking25.
However, the results of this study in stroke patients show that there were no significant differences in spatiotemporal parameters in dual motor tasks compared with those of the single motor task. The major changes were only observed in the proximal joint angles, especially the angles of the trunk, pelvis, and hip joints, which were significantly larger in dual motor tasks than in single walking tasks. This might be related to the obvious motor deficit of recruited stroke patients compared with the elderly or cognitively impaired patients (their basic motor function is preserved). There might be similar difficulties while performing a simple motor task and a complex motor task in stroke patients with existing impaired motor function, which could explain why the spatiotemporal parameters and distal joint angle were not sensitive parameters for the comparison between single and dual motor tasks in stroke patients. Additionally, these results suggest that rehabilitation training to increase trunk and large joint control might help stroke patients improve their ability to perform complex daily motor activities.
The heterogeneity of stroke patients has always been the main obstacle in many investigations26. A previous study had explored the use of the DTC value (the dual-task consumption ratio as the difference between a single task and double tasks) to eliminate the heterogeneity between stroke patients10. Indeed, the representative results demonstrate that the bilateral joint angle parameters of the large proximal joints in the complex dual walking task are significantly larger than those in the simple motor dual-task, indicating the advantages of using the DTC values in dual-task gait assessment for stroke patients.
This study has three main limitations. First, as this study is mainly a methodological demonstration of dual-motor tasks, the representative data only included data of 18 male stroke patients. In addition, previous studies have suggested that both gender and age impact gait and balance function. For example, as age increases, the ability to control posture decreases, and women are more affected than men. Moreover, the lack of significant difference in spatiotemporal parameters found in this study might be simply because of the sample size. Hence, further studies are needed to increase the sample size and include female subjects to extend the clinical application of this assessment. In conclusion, through dual-motor walking tasks and the calculation of DTC values, this research protocol aims to provide a basis for the clinical diagnosis of gait function and an in-depth study of motor control in stroke patients.
The authors have nothing to disclose.
We thank Anniwaer Yilifate for proofreading our manuscript. This study was supported by the National Science Foundation under Grant No. 81902281 and No. 82072544, the General Guidance Project of Guangzhou Health and Family Planning Commission under Grant No. 20191A011091 and No. 20211A011106, the Guangzhou Key Laboratory Fund under Grant No. 201905010004 and Guangdong Basic and Applied Basic Research Foundation under Grant No.2020A1515010578.
BTS Smart DX system | Bioengineering Technology System, Milan, Italy | 1 | Temporospatial data collection |
BTS SMART-Clinic software | Bioengineering Technology System, Milan, Italy | 2 | Data processing |
SPSS software (version 25.0) | IBM Crop., Armonk, NY, USA | Statistical analysis |