A comparison between single task versus dual task condition balance training in older

adults with balance impairment

Meenakshi Verma1, Stuti Sehgal2
1 Research student, ISIC Institute of Health and Rehabilitation Sciences, New Delhi
2 Research guide, M.P.T Neurology, Lecturer, ISIC Institute of Health and Rehabilitation Sciences, New Delhi
Abstract
Background and Purpose - Traditionally, rehabilitation programs emphasize training under single-task conditions to improve balance and reduce for
falls. The purpose of the study was to compare the efficiency of three different balance training strategies in an effort to understand the mechanisms
underlying training-related changes in dual task balance performance of older adults with balance impairment.
Methods - 45 older adults with balance impairment were recruited and randomly assigned to three groups. Group one received single task balance
training, group two received dual task training balance training under fixed priority, group three received dual task balance training under variable
priority. Subjects received one hour individualized training sessions, five times in a week for two weeks. Berg balance scale, time up and go test and
dynamic gait index were the outcome measure and their scores for all groups were taken prior and after the training.
Results - One way analysis of variance was used to analyse the difference among the balance improvement in Group one, two and three. And the results
revealed that post intervention scores were highly significant (p 0.05) in group two and group three performed better than group one.
Conclusion - In conclusion, dual task training is effective in improving balance under dual task context in older adults with balance impairment, and
single task training may not generalize to balance performance under dual task conditions.
Keywords - Balance, Fall, Berg balance scale, Time up and go test, Dynamic index gait, Dual task.

Introduction
Falling is one of the most serious problems associated
with ageing.1 Falls are the most frequent cause of injury- related
morbidity and mortality among the elderly. The risk of falling
exceeds 20% per year among persons aged 65 and older and
living in the community and reaches 35% per year among those
75 and older.2,3
Falls are costly and have potentially devastating
physical, psychological and social consequences. Several
studies have been performed among both home living and
institutionalized populations to define risk factors associated
with falls.11-15
These risk factors have included both- intrinsic or
personal factors (example- Balance impairment, neurological
disorders, postural hypotension, and medication use)1,8,10,16-18
and extrinsic or environmental factors (example- Ill fitting
footwear, poor lighting, slippery surface and inappropriate
furniture.1,8-10,18-20
There are multifactorial intervention have been
introduced which included eliminate environmental hazards,
improve home support, provide opportunities for socialization
and encouragement, modify medication, provide balance
training, involve family and provide follow up.9,21,22
Keeping this in mind, this study is designed with the
purpose of identifying the most appropriate balance training
program under single and dual task condition in older adults
with balance impairment because no research have examined
the effects of training balance under single task versus dual task
(fixed priority versus variable priority) conditions in older
adults.
Single task training involves practicing functional task
requiring balance (example Standing, walking, transfer) in
isolation. In previous researches, the therapist may vary the
condition to increase the challenge to balance during

performance under which the subject practices for example

changing the availability of sensory cues (reduce visual cues by
asking the participants to close your eyes), or support surface
conditions (example- Walking on a flat surface versus an
inclined surface. 23-24
Dual task method, which requires participants to
perform multiple tasks simultaneously, has been used to
investigate the effect of cognitive tasks on postural control and
vice-versa. It has been shown that the ability to maintain
postural stability is reduced when performing two or more tasks
concurrently & these deficits are increased in elderly people
with balance impairment.25-28
Some studies compared the effectiveness of
whole/dual-task training under various set of instructions (fixed
priority versus variable priority). In fixed priority condition,
participants were asked to place the same amount of attention on
both tasks at all times, whereas in variable priority condition,
attention was switched between tasks.
Kramer et al31 compared dual task training under two
instructional sets; fixed priority and variable priority
instructional sets. In their study included a monitoring task in
conjunction with an alphabet-arithmetic task. Results showed
that the variable priority group improved (increased accuracy
and decreased response time) significantly more than fixed
priority group and dual task processing skills learned during
variable priority training transferred to novel tasks. In this study,
the effect of instructional set on dual task balance training in
elders is not known. In light of research indicating that inability
to perform concurrent tasks is a contributing factor to instability
and falls in many older adults, it has been suggested that
training under both single and dual task condition is necessary
to optimize functional independence and reduce falls in elderly
people. So my purpose of study is to compare the effects of
training balance under single task versus dual task (fixed

A comparison between single task versus dual task condition balance training in older adults with balance impairment
priority versus variable priority) in older adults with balance
impairment.
Three balance scales are used to assess the outcomes of
both interventions. They are Time Up and Go Test, Berg
Balance Scale and Dynamic Gait Index. These scales have good
reliability and validity. These scales have been selected for
study because
1. They are very simple to administer
2. They are quick and practical.
3. They are easy to be conducted in Indian clinical setting
4. The contents of these scales closely mimic the day to
day activities and are easy for the patients to
understand.

1 while simultaneously performing auditory and visual

discrimination tasks as well as cognitive tasks such as
substraction and subjects were directed to maintain attention on
both postural and secondary tasks at all times.
Group 3 received Dual task condition training under
variable priority which included half training was done with a
focus on postural task performance, and half had a focus on
secondary task performance such as semi tandem with eyes
closed and arm alteration was postural task and spell word
backward is secondary task and attention was switched between
the task.
Subjects were then assessed on three balance scalesBerg Balance Scale, Time Up and Go Test, Dynamic Gait Index

Methods

Statistics

A sample of convenience of 45 older adults with

balance impairment took part in this study. Subjects were
gathered through a Free Physiotherapy Camp organized at
Sarvodaya Hospital and community center at Ghaziabad and
ISIC, Hospital, New Delhi. Subjects who fulfilled the inclusion
criteria and were ready to attend exercise program regularly
were selected.
To participate subjects had to meet the inclusion
criteria: (i) Subjects with age of 65 of years or above. (ii)
Subjects with history of one fall within the previous year.(iii)
Independent ambulators with ability to walk 9 meter without
any assistance.(iv)Subjects who were independent in their
activities of daily living. (v) Subjects who scored greater than 24
on mini mental status examination score.39
Exclusion Criteria for the subjects were: (i) History of
any other severe neurological, musculoskeletal and
cardiovascular condition that affected balance. (ii) Any history
of dizziness, depression. (iii) Any uncorrected severe hearing &
visual impairment which will affect the balance in elderly. (iv)
Receipt of physical therapy or enrollment in any other formal
exercise program at the same time.

Technical information
A pre-post experimental design was used. The subjects
were invited to participate in the study and were divided
accordingly into three groups. A detailed explanation of the
procedure was given to the patients after which they signed
informed consent. Then the subjects were assessed on 3 balance
scales included in our study: Berg balance scale, time up and go
test, dynamic gait index. Balance training sessions followed
Gentiles taxonomy of movement tasks, a theoretical framework
for retraining motor control.
Group 1 received Single task condition training which
included balance activities such as standing with reduced base
of support, tandem standing, standing with eyes closed.
Group 2 received Dual task condition training under
fixed priority which included same set of balance tasks as group

The data was managed on excel spread sheet and was

analyzed using SPSS (Statistical Package for social sciences for
windows) software, version 12. A One way analysis of variance
was used to analyze the difference among the balance
improvement in Group 1, 2, 3. Post hoc analysis of significant F
ratio (p 0.05) was conducted using Duncan mean test. Student
t- test (paired) used to analyze the difference between the
balance improvements within the group. A significance level of
p 0.05 was fixed.

Results
The group 1 receiving single task condition balance
training program consisting of 12 males and 3 female with a
mean age of 68.47 years. Group 2 receiving dual task condition
with fixed priority balance training program consisting of 12
males and 3 females with a mean age of 68.20years. Group 3
receiving dual task condition balance training with variable
priority balance training program consisting of 12 males and 3
females with a mean age of 68.07 years. All three groups were
matched in terms of age, height, weight (table 1.1. and figure
1.1). One way analysis of variance was used to compare the
performance of subjects of group 1, 2, 3 on Berg balance scale,
Time up and go test, Dynamic gait index.
Figure 1.1. Comparison of age among the group 1, 2, 3
Group 1 = Single task condition balance training
Group 2 = Dual task condition balance training
Group 3 = Dual task condition balance training
Comparison of age among the group 1, group 2 and
group 3
72
71
70
69
Age (years)

Selection and description of participants

68
67
66
65
64
63
Age

Group 1

Group 2

Group 3

68.47

68.2

68.07

A comparison between single task versus dual task condition balance training in older adults with balance impairment

Table 1.1. Demographic Data: Comparison among Group 1, Group 2, Group3 (One way ANOVA)
Gp 1 (n = 15)
Mean (SD)
68.47 (2.66)

Variables
Age ( year )
Height ( cm )

165.93 (11.61)

Gp 2 (n = 15)
Mean (SD)
68.20 (2.21)
164.93 (10.35)

Gp 3 (n =15)
Mean (SD)
68.07 (2.12)
164.33 (10.37)

Weight ( kg )

61.66 (6.04)

60.93 6.06)

60.80 (5.88)

Gender

Male = 12
Female = 3

Male = 12
Female = 3

Male = 12
Female = 3

p value

0.113

NS

0.893

0.084

NS

0.9195

0.0907

NS

0.9134

Not significant at p 0.05 level

number of subjects
Group
Single task condition balance training
Dual task condition with fixed priority balance training
Dual task condition with variable priority balance training

Figure 1.2. Comparison of pre and post intervention of berg

balance scale scores among group 1, 2, 3
BBS0 = Pre-intervention scores of Berg balance scale
BBS1 = Post-intervention score of Berg balance scale
Comparison of pre and post intervention BBS scores
between group 1, group 2 and group 3
58

Berg Balance Scale Scores

Pre-intervention scores of Berg balance scale (figure 1.2)

All the groups did not showed significant difference
(F= 0.8543, p 0.05) indicating that all three groups were
matched in terms of Berg balance scale. Group 1 (mean= 49.55,
SD=1.88), Group 2 (mean= 50.33, SD= 1.75), Group 3 (mean=
50.20,SD= 1.74).
Pre-intervention scores of Time up and go test for balance
(figure 1.3)
All the groups did not showed significant difference
(F= 0.5513, p 0.05) indicating that all three groups were
matched in terms of Time Up and Go Test. Group1 (mean=
11.14, SD= 1.24), Group2 (mean= 11.33, SD= 1.03), Group3
(mean= 11.57, SD=1.06).
Pre- intervention scores of Dynamic gait index for balance
(figure 1.4)
All the groups did not showed significant difference
(F= 0.7434, p0.05) indicating that all three groups were
matched in terms of Dynamic Gait Test. Group 1 (mean= 20.40,
SD= 1.05), Group 2 (mean= 20.40, SD= 1.18), Group 3 (mean=
20.00, SD= 0.84)
Post- intervention scores of Berg balance scale (figure 1.2)
Results revealed significant difference in group 1
versus group 2 and group 1 versus group 3 with F value=
9.1953, p 0.05. Group 1 (mean=54.33, SD=1.63), Group 2
(mean= 55.66, SD= 0.48), Group 3 (mean= 55.80, SD= 0.56)
Post- intervention scores of Timed up and go test (figure1.3)
Results revealed significant difference in group 1
versus group 2 and group 1 versus group 3 with F= 6.68451,
p0.05. Group 1 (mean =9.70, SD= 0.80), Group 2 (mean =
8.80, SD= 0.84), Group 3 (mean = 8.72, SD= 0.75)
Post- intervention scores of Dynamic gait scale (table 1.3 and
figure 1.4)
Results revealed no significant difference in among all
three groups with F= 1.4135, p 0.05. Group 1 (mean=23.53,
SD =0.74), Group 2 (mean = 23.80, SD= 0.41), Group 3 (mean
= 23.86, SD=0.51).

56
54
52
50
48
46
44
42

Group 1

Group 2

Group 3

BBS0

49.55

50.33

50.2

BBS1

54.33

55.66

55.8

Figure 1.3. Comparison of pre and post intervention of time up

and go test scores among group 1, 2, 3.
TUGT0 = Pre-intervention scores of Time Up and Go Test
TUGT1 = Post-intervention score of Time Up and Go test
Comparison of pre and post intervention TUGT scores
between group 1, group 2 and group 3
14
Timed Up and Go Test Scores (sec)

NS
=
n
=
Gp
=
Group 1 =
Group 2 =
Group 3 =

F value

12
10
8
6
4
2
0

Group 1

Group 2

Group 3

TUGT0

11.14

11.33

11.57

TGUT1

9.7

8.8

8.72

A comparison between single task versus dual task condition balance training in older adults with balance impairment
Figure 1.4. Comparison of pre and post intervention scores of
dynamic gait index among group 1, group 2 , group 3
DGI = Dynamic Gait Index
DGI0 = Pre-intervention scores of Dynamic gait index
DGI1 = Post intervention scores of Dyanmic gait index
Comparison of pre and post intervention DGI
scores between group 1, group 2 and group 3
Dynamic Gait Index Scores

30
25
20
15
10
5
0
Group 1

Group 2

DGI0

20.4

20.4

Group 3
20

DGI1

23.53

23.8

23.86

Discussion
The results of study have revealed that subjects in
group 1 (single task condition balance training), group 2 (dual
task condition balance training with fixed priority), group 3
(dual task condition balance training with variable priority)
benefited from balance training intervention with a significant
improvement in post- intervention balance scores on Berg
balance scale, Time up and go, but results did not show the
significant improvement on Dynamic gait index. Although
Dynamic gait index have shown improvement with in all three
groups.
Secondarily, post intervention scores were highly
significant in among the groups but group 2 and group 3
performed better than group 1. So dual task condition balance
training program was found to be more effective in improving
balance in older adults with balance impairment.
One factor that might have contributed to improved
scores in group 2 and group 3 could be based on task
coordination and management theory proposed by Kramer et al.
According to this theory practicing two tasks together (not a
single task practice) allows participants to develop task
coordination skills. Thus, a possible explanation of this outcome
is that the efficient integration and coordination between the two
tasks acquired during dual task training is crucial for improving
dual task performance. Alternatively, according to Task
Automatization hypothesis, practicing only one task at a time
(single task training) allows participants to automatize the
performance of individual tasks. As a result, the processing
demand required to perform the tasks is decreased, leading to
more rapid development of skills.33-36
Another factor that might have contribute to improved
scores in group 2 and group 3 was that they had instructional set
in dual task training. Research by Kramer et al suggests that
who receive dual task training with variable priority instructions
have advantage over those who receive training with fixed
priority instructions. These researchers found that participants in

dual task training groups with either fixed priority or variable

priority instructions could learn to coordinate the two tasks.
However, after training, the processing demand required to
perform the tasks was less when their attention was shifted
between the two tasks, as was required in dual task training with
variable priority instructions group. This could explain why the
participants in our dual task training with variable instructions
group were able to learn faster. Although in our results we could
not found a significant difference between fixed priority and
variable priority instruction but the subjects who received
variable priority have done less number of miss steps and less
errors in verbal response during the intervention period as
compare to fixed priority instructional sets.32-34
After two weeks intervention program, subjects in all
training groups significantly improved performance on Berg
balance score and Time up and go. But results did not show the
significant improvement on Dynamic gait index. Although
Dynamic gait index have shown improvement with in all three
groups. No research studies have examined that support the
dynamic gait index is improved in dual task condition balance
training. Might be the rate of learning and retention phase was
not appropriate. Thus, the outcomes suggest that dual task
condition balance training is more effective than single task and
the importance of instructional set during balance training.

Conclusion
The result of the present study clearly states that dual
task training is effective in improving balance under dual task
context in older adults with balance impairment, and single task
training may not generalize to balance performance under dual
task conditions. The instructional set was an important in dual
task performance. The variable priority instructional set offered
advantages over the fixed priority instructional set in terms of
the rate of learning and ability to maintain the skill level
achieved during training. Although in our results we could not
found a significant difference between fixed priority and
variable priority instruction but the subjects who received
variable priority have done less number of miss steps and less
errors in verbal response during the intervention period as
compare to fixed priority instructional sets.
Thus, the alternate hypothesis stated in the beginning
of the study, that is, Dual task condition balance training acts as
better technique from single task balance training in older adults
with balance impairment, have been proved.

Clinical Implication
This study found that it was feasible to implement
individual dual task training, combining
traditional
intervention with a variety of cognitive tasks, in communitydwelling older adults with balance impairment. We also found
that older adults could in fact adhere to instructional sets
regarding attentional forces. They successfully allocated their
attention to task in which they were instructed. Thus, results

A comparison between single task versus dual task condition balance training in older adults with balance impairment
may generalize to similar older adults with balance impairment,
excepting those with a significant neurological or
musculoskeletal diagnosis.

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