941142

research-article2020
CRE0010.1177/0269215520941142Clinical RehabilitationLi et al.

CLINICAL
Original Article REHABILITATION

Clinical Rehabilitation

Dual-task training on gait, motor 1­–13

© The Author(s) 2020
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DOI: 10.1177/0269215520941142
https://doi.org/10.1177/0269215520941142

with Parkinson’s disease: a journals.sagepub.com/home/cre

systematic review and meta-analysis

Zhenlan Li1,2 , Tian Wang1, Haoyang Liu2, Yan Jiang1,

Zhen Wang3 and Jie Zhuang1

Abstract
Objective: The aim of the present study was to systematically evaluate and quantify the effectiveness
of dual-task training on gait parameters, motor symptoms and balance in individuals diagnosed with
Parkinson’s disease.
Data resources: A systematic review of published literature was conducted until May 2020, using
PubMed, EMBASE, Cochrane Library, Web of Science, EBSCO and CNKI databases.
Methods: We included randomized controlled trials (RCTs) and non-RCTs to evaluate the effects of
dual-task training compared with those of non-intervention or other forms of training. The measurements
included gait parameters, motor symptoms and balance parameters. Methodological quality was assessed
using the PEDro scale. Outcomes were pooled by calculating between-group mean differences using
fixed- or random-effects models based on study heterogeneity.
Results: A total of 11 RCTs comprising 322 subjects were included in the present meta-analysis. Results
showed that dual-task training significantly improved gait speed (standardized mean difference [SMD],
−0.23; 95% confidence interval [CI], −0.38 to −0.08; P = 0.002), cadence (SMD, −0.25; 95% CI, −0.48 to
−0.02; P = 0.03), motor symptoms (SMD, 0.56; 95% CI, 0.18 to 0.94; P = 0.004) and balance (SMD, −0.44;
95% CI, −0.84 to −0.05; P = 0.03). However, no significant changes were detected in step length or stride
length.
Conclusion: Dual-task training was effective in improving gait performance, motor symptoms and
balance in patients with Parkinson’s disease relative to other forms of training or non-intervention.

1
S chool of Sport Science, Shanghai University of Sport, Corresponding authors:
Shanghai, China Zhen Wang, School of Martial Arts, Shanghai University of Sport,
2
Department of Rehabilitation Sciences, Ningbo College of 399 Changhai Road, Yangpu District, Shanghai 200438, China.
Health Sciences, Zhejiang, Ningbo, China Email: wangzhen@sus.edu.cn
3
School of Martial Arts, Shanghai University of Sport, Jie Zhuang, School of Sport Science, Shanghai University of
Shanghai, China Sport, 399 Changhai Road, Yangpu District, Shanghai 200438,
China.
Email: zhuangjiesh@163.com
2 Clinical Rehabilitation 00(0)
Keywords
Dual-task training, Parkinson’s disease, systematic review, meta-analysis
Received: 25 February 2020; accepted: 15 June 2020
Introduction
Daily activities require walking while concurrently
performing cognitive and/or motor tasks, such as
talking with a friend or carrying a glass of water.
Carrying out another task while walking is a com-
mon dual-task, which occurs in combination with
cognition to execute multiple tasks in parallel.
However, gait deficiency in patients with
Parkinson’s disease is exacerbated under dual-task
conditions,1 which seriously impact walking per-
formance.2 Compared with parameters in healthy
controls, dual tasks induce specific decreases in
walking velocity, step length and stride frequency,
as well as increases in stride variability, in patients
with Parkinson’s disease.3–5 During performance of
a secondary task while walking, patients with
Parkinson’s disease may concentrate too heavily
on the secondary task and pay less attention to the
act of walking, thus increasing the risk of falling.6
Although the underlying mechanisms of dual-
task impairment remain unclear, such mechanisms
may be partially explained by theories related to
capacities and bottlenecks. Two concurrent tasks
compete for limited resources, inducing dual-task
interference and deterioration in performance of one
or both tasks.1 Dual-task performance depends on
the ability to perform motor tasks automatically and
the cognitive (executive) ability to combine differ-
ent types of tasks.7 Nevertheless, dual-task gait defi-
ciency is not alleviated via dopamine replacement
therapy.8 Targeted motor/cognitive dual-task train-
ing leads to improvements in single- and dual-task
walking, as well as in modest improvements in bal-
ance.9 The effects of dual-task training on gait and
postural instability in Parkinson’s disease have been
supported by an increasing number of reported tri-
als.10,11 Cognitive-coupled intensive-balance train-
ing is a proven and cost-effective therapy for
improving balance and reducing falls in patients
with neurological disorders.12 A meta-analysis has
suggested a positive impact of dual-task training for
enhancing postural stability among the fall-prone
elderly population and those suffering from stroke.13
Furthermore, physical exercise interventions associ-
ated with cognitive exercise enhance postural con-
trol and frontal cognition in individuals with
Alzheimer’s disease.14 In addition, evidence from
virtual reality incorporating motor training has fur-
ther demonstrated that intervention-targeted dual-
task training can increase gait speed, step length and
step time.7,8 Taken together, these previous findings
suggest that the addition of a cognitive task to a
motor task can generate positive effects on gait and
balance function without increasing the risk of
falling.
However, it is unknown how dual-task or
multiple-task interventions contribute to improved
gait performance and other motor functions in
patients with Parkinson’s disease. Specifically, no
meta-analyses have evaluated whether dual-task
training improves spatiotemporal gait parameters,
as well as motor symptoms and balance.15 Hence,
the purpose of the present review was to analyze
the characteristics of gait parameters after dual-
task training in individuals with Parkinson’s dis-
ease, and to examine the effect of dual-task training
on gait, motor symptoms and balance.
Methods
Data sources and search strategy
Electronic literature searches of English and
Chinese language articles were conducted from the
inception of the following databases until May
2020: PubMed, EMBASE, Cochrane Library, Web
of Science, EBSCO and CNKI. The search terms
included ‘Parkinson’, ‘Parkinson’s disease’, ‘PD’,
‘dual task’, ‘concurrent task’, ‘gait’, ‘walk’ and
‘locomotion’ (see the Supplemental Appendix).
The protocol was registered into the international
Li et al. 3
prospective register of systematic reviews in 2018
(PROSPERO registration number: CRD4201810
6732).
Inclusion and exclusion criteria
This systematic review included studies that ful-
filled the following criteria: (1) adult participants
diagnosed with Parkinson’s disease; (2) dual tasks
(i.e. cognitive-motor) were used as part of the
intervention; (3) gait parameters, motor symptoms
and balance were evaluated as the primary out-
comes; (4) results were reported in English and
Chinese; (5) the study design involved randomized
controlled trials (RCTs) or non-randomized con-
trolled trials (non-RCTs); and (6) the study included
independent samples.
The exclusion criteria were as follows: (1) dual
tasks were used as an assessment tool; (2) the effects
of combining dual tasks with other non-motor ther-
apies were investigated; or (3) the results involved
cognitive functioning as the primary outcome.
Formal meta-analysis included only RCTs, whereas
non-RCTs were only used for qualitative synthesis
of overall evidence. Two authors reviewed the titles
and abstracts, and independently assessed the arti-
cles for eligibility. Full-text copies were reviewed if
the title and abstract did not provide details to con-
firm study inclusion. Any unclear information was
obtained via e-mail or fax addressed to the corre-
sponding author. Disagreements were resolved via
third-party consensus.
Data extraction
The extracted data from the articles included the
following: (1) basic characteristics, namely the
title, authors, publication status, publication year,
literature sources, the country in which the trial
was conducted, publication language, total sample
size and study design; (2) characteristics of partici-
pants, namely age, disease duration, severity of
motor symptoms and the stage of Parkinson’s dis-
ease; and (3) the means and standard deviations
(SDs) of statistical measures of gait parameters
and balance function before and after dual-task
training.
Quality and risk-of-bias assessments
Two reviewers (Z.L. and T.W.) independently
assessed the methodological quality of each of the
included studies based on the PEDro scale,16 which
consists of 11 items. The rating scale was as fol-
lows: <4 was ‘poor’, 4–5 was ‘fair’, 6–8 was
‘good’ and 9–10 was ‘excellent’. Higher scores
indicated superior methodological quality.
Importantly, the PEDro scale is a reliable rating
scale to assess the methodological quality of clini-
cal trials, especially RCTs.16 Any discrepancies in
the assessments were resolved via discussion
between the two authors (J.Z. and Z.W.).
Data synthesis and analysis
The results of the outcome measures obtained from
the studies were processed using Review Manager
(version 5.3, the Cochrane Collaboration) and
Stata/MP (version 14.1, the Stata Corp). The
pooled data were analyzed as standardized mean
differences (SMDs) and 95% confidence intervals
(CIs), as this method was appropriate for compari-
sons of different scales of outcome measurements.
Thresholds for the interpretation of effect size
were used in the SMDs, as follows: ⩽0.2 = small,
>0.2−0.5 = moderate, >0.5−0.7 = large and >0.7 = 
very large.15,17 Heterogeneity among the studies
was evaluated using a chi-squared test and the I2
statistic. A fixed-effects model was used when the
values that exceeded 50% of the interpreted value
were of considerable heterogeneity; otherwise the
random-effects model was utilized. A P < 0.1 was
indicative of significant heterogeneity. The results
of meta-analysis were considered if the 95% CIs of
the Forest plot did not include 0. A P < 0.05 was
considered statistically significant.2,15 Sensitivity
analysis was used to test the stability of the results
by removing each study one by one.
Results
Description of included studies
Our present meta-analysis included 11 RCTs com-
prised of a total of 322 patients with Parkinson’s
disease. The selection flow diagram is depicted in
4 Clinical Rehabilitation 00(0)
Figure 1. All study participants were diagnosed with
idiopathic Parkinson’s disease at Hoehn and Yahr
stages18 ranging from 1 to 4. The average age of the
participants was 66.85  ± 6.45 years. All patients
included in the RCTs were on a stable medication
regimen.18–28 With the exception of one study, all
other studies involved assessments at the ‘on’ status
of medications.29 As shown in Table 1, the interven-
tions in the experimental group involved two differ-
ent types of tasks, whereas the control group either
performed one type of approach or maintained regu-
lar activities. The duration of the intervention group
ranged from 4 to 48 weeks. The measured outcomes
included gait function, balance and motor symp-
toms. Six non-RCT studies mainly explored one-
session or short-term training, and gait parameters
were the primary outcomes in these studies. Two
studies reported adverse events because of falls dur-
ing training,22,26 but none of the events interfered
with training or other activities. No other studies
reported any serious adverse effects.
The PEDro scores of the included studies were
between 5 to 9 and 10 studies had scores of 6 or
higher (accounted for 90% of all studies). The
majority of studies described detailed baselines,
random and concealment allocations and blind con-
ditions of the experimenters, but no studies reported
that subjects were also blind to the experimental
conditions. Six articles performed intention-to-treat
analysis. Only one article reported a dropout rate
<15%. No selective reporting of outcomes was
found in any of the included studies. The total
scores for each the studies are presented in Table 2.
Outcome measures and main findings of
included studies
Gait speed. Results of the random-effects model
indicated that dual-task training prominently
improved gait speed relative to that of the control
group, with a small effect (SMD, −0.23; 95% CI,
−0.38 to −0.08; P = 0.002; I2, 0%; Figure 2). The
subgroup analysis of gait speed was based on the
single- and dual-task conditions. Dual-task training
significantly improved gait speed compared with
that of the control group under the single-task
condition (SMD = −0.29; 95% CI, −0.47 to −0.10;
P = 0.002; I2, 0%; Figure 2), but gait speed showed
no statistically significant difference under dual-
task conditions (SMD, −0.13; 95% CI, −0.38 to
0.12; P = 0.30; I2, 0%; Figure 2). Furthermore, no
significant difference was observed between sin-
gle- or dual-task conditions for gait speed. Lack of
heterogeneity persisted in both total-group and
subgroup analyses. Four non-RCTs reported statis-
tically significant increases in gait speed under
single-task conditions,30,31,33,34 while one non-RCT
demonstrated improvement in gait speed under
dual-task conditions.32 The gait speed improve-
ment in both conditions was reported only in one
non-RCT study.33
Step and stride lengths.  Step and stride lengths did
not differ between the dual-task training group and
the control group (SMD, −0.14; 95% CI, −0.33 to
0.05; P = 0.16; I2, 0%; Figure 2). The subgroup
analysis also yielded the same result, suggesting a
lack of significant improvement in step and stride
lengths (SMD, −0.05; 95% CI, −0.33 to 0.21;
P = 0.73; I2, 0%; SMD, −0.26; 95% CI, −0.55 to
0.03; P = 0.08; I2, 0%; Figure 2) compared with
those from regular activities or separate motor- and
cognitive-training interventions. No significant
heterogeneity was detected in terms of step length,
and heterogeneity was considerably small in terms
of stride length. However, three non-RCTs sug-
gested a remarkable increase in the step and stride
lengths after dual-task training,31,33,34 and one non-
RCT reported that dual-task training had no effect
on step length or stride length.30
Cadence.  Cadence results were reported in six
RCTs, from a total number of 145 participants in
the dual-task training groups. The meta-analysis
based on random effects revealed a significant
improvement in cadence (SMD, −0.25; 95% CI,
−0.48 to −0.02; P = 0.03; I2, 0%18,21–23,26,28; Figure
2). There was no significant heterogeneity tested
among these studies. One non-RCT demonstrated
positive retention effects in cadence,34 while
another study showed no significant changes in
cadence under single- or dual-task conditions.30
Table 1.  Characteristics of included studies.
Study Study type Sample Mean age H&Y Med Type of dual-task Frequency (per Duration Control group Measure outcome
Li et al.

week) (weeks)

Rosenfeld et al.22 RCT 10 59 ± 9 2–4 On Simultaneous gait and 45 minutes, 3× 8 Single-model Gait velocity, cadence,
cognitive training training stride length, step
width, arm swing
Yang et al.21 RCT 6 69.5 ± 18.3 1–3 On Motor dual-task and 30 minutes, 3× 12 General gait Gait speed, stride
cognitive dual-task training length, cadence, double
support time
Geroin et al.19 RCT 56 65.8 ± 9.19 2–3 On Performed the 40 minutes, 4× 6 Separate Gait parameter, (stride
same cognitive tasks training of length, cadence, stride
and gait exercises motor and time)
simultaneously cognitive
Beck et al.20 RCT 40 68.8 ± 10.08 1–3 On Walking combined 1 hour, 3× 11 No exercise Gait parameter
with external or (velocity, step length,
internal focus of step length variability),
attention exercise UPDRS-III
Vergara-Diaz et al.27 RCT 16 65.7 ± 3.85 1–2.5 On Combined motor 1 hour, 2× 24 Usual health Gait parameter (speed,
with multiple care stride time variability),
cognitive components UPDRS-III
(mindfulness, focused
attention, DT and
mindful breathing)
Wallen et al.24 RCT 51 73.1 ± 5.8 2–3 On Combining cognitive 1 hour, 3× 10 Care as usual Gait velocity, Mini-
tasks (e.g. counting) BESTest
with motor tasks
(e.g. carrying or
manipulating objects)
Tedla et al.23 RCT 15 67.73 2 On Walked concurrent 1 hour, 3× 4 Cognitive Gait parameter (speed,
with holding a tray in training cadence, stride length)
hand
Conradsson et al.26 RCT 47 72.9 ± 6.0 2–3 On Balance exercises 1 hour, 3× 10 Maintain Gait parameter
combined with normal physical (velocity, step length,
cognitive (i.e. counting) activities cadence), UPDRS,
and/or motor tasks Mini-BESTest
(i.e. carrying objects)
Wong-Yu and Mak RCT 41 59.4 ± 9.0 1–3 On Performed daily task 1 hour, 1× 8 Upper limb Gait speed, TUG,
(2015)25 (i.e. head turns, talking training ABC, BESTest
on phone, shopping)
while walking
Duncan and Earhart29 RCT 26 69.3 ± 1.9 1–4 Off Community-based 1 hour, 2× 48 No Gait velocity, UPDRS-
tango programme intervention III, Mini-BESTest,
involved walking while FOG-Q, 6MWT
naming words)
5

(Continued)
 6
Table 1. (Continued)

Study Study type Sample Mean age H&Y Med Type of dual-task Frequency (per Duration Control group Measure outcome
week) (weeks)

de Bruin et al.28 RCT 11 64.1 ± 4.2 2–3 On Music and cognitive 30 minutes, 3× 13 Kept regular Gait parameter
task while walking activities (velocity, stride length,
cadence), UPDRS-III
Mirelman et al.30 Repeated 20 67.1 ± 6.5 2–3 On Walking in VR 45 minutes, 3× 6 None Gait parameter (speed,
measures environment with stride length, stride
design imposed cognitive time), UPDRSIII
load that demanded
attention
Killane et al.8 Non-RCT 20 64.2 ± 2.4 1–3 On Combined motor- 25 minutes, 4× 2 None Gait parameter
cognitive VR-based (stepping time)
intervention
Fok et al.31 Non- 6 73 ± 12 1–3 On A verbal-cognitive task 30 minutes None None Gait parameter
randomized combined with walking (velocity, stride length,
mixed design accurate enumeration
rate)
Yogev-Seligmann Non-RCT 7 63.8 ± 8.4 2–3 On Walking while 25 minutes, 3× 4 None Gait parameter (gait
et al.32 performing verbal speed, stride time
fluency (VF) task, serial variability)
three-subtraction task,
information processing
task
Brauer and Morris33 Test–retest 20 68.5 ± 11.3 2–3 On Walking while 20 minutes None None Gait parameter (step
experimental concurrently length, speed, cadence,
design performing working double support time)
memory language and
counting tasks with
verbal responses
Canning and Elke Repeated 5 61 ± 8 1–3 On Walking while 30 minutes, 1× 3 None Gait parameter
Woodhouse34 measure performing various (velocity, stride length,
study additional cognitive, cadence)
manual and triple tasks

ABC: Activity-specific Balance Confidence scale; BESTest: Balance Evaluation Systems Test; FOG-Q: freezing of gait questionnaire; H&Y: Hoehn and Yahr stage; Med: anti-
Parkinson medication (‘off’ refers to medication-off measurement); Mini-BESTest: Mini-Balance Evaluation Systems Test; 6 MWT: 6 minutes walking test; NFOG-Q: new
freezing of gait questionnaire; TUG: timed up and go; UPDRSIII: part III of Unified Parkinson’s disease rating scale; VR: virtual reality.
Clinical Rehabilitation 00(0)
 Li et al. 7

Motor symptoms. Three RCTs and one non-RCT

evaluated motor symptoms via UPDRSIII.27–29,30,32
(0–10)
Total
UPDRSIII is the motor-section subscale of the

7
7
7
6
7
6
7
9
6
7
5
comparisons measures and Unified Parkinson’s Disease Rating Scale
measures of (UPDRS) and has been shown to measure disease
Reporting

variability progression and severity, as well as the response of

of point

Yes motor function to therapy. Lower scores reflect less

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
severity of motor symptoms.35,36 A random-effects
model was used for meta-analysis and showed a
large overall size (SMD, 0.56; 95% CI, 0.18 to
Assessors <15% Intention Between-

0.94; P = 0.004; I2, 0%; Figure 3), thereby demon-

dropouts to treat group

strating that dual-task training significantly

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
improved motor symptoms compared with those in
the control groups. No significant heterogeneity
was observed in these studies. Moreover, non-
Yes

Yes
Yes
Yes
Yes
Yes
No
No

No

No
No RCTs found significant within-group improve-
ments at post-intervention.30
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
Yes
Yes
No

Balance function. In addition to one study that

applied the Balance Evaluation Systems Test to
Unclear
blinded

assess balance,25,37 there were three studies that

Yes
Yes
Yes
Yes
Yes

Yes
Yes
Yes
Yes
No

used the Mini-Balance Evaluation Systems

Test.24,26,29 Therefore, these studies were included
Random Concealed Similar at Subjects Therapists

in our meta-analysis. Results from the random-

Unclear
Unclear
Unclear
Unclear
Unclear
Unclear

Unclear

Unclear
allocation allocation baseline blinded blinded

effects model indicated that dual-task training had

Yes
No

No

a significant improvement on balance function

compared with that of the control groups (SMD,
−0.44; 95% CI, −0.84 to −0.05; P = 0.03; I2, 56%;
No
No
No
No
No
No
No
No
No
No
No

Figure 3), indicating large heterogeneity in terms

of this parameter.
Table 2.  Quality assessment of the included studies.

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

Publication bias.  A funnel plot was applied to ana-

lyze publication bias. The effect size estimated
from individuals was used to measure the precision
Unclear

Unclear

Unclear

Unclear

generated from a symmetrical plot, indicating little

Yes
Yes
Yes

Yes

Yes
Yes

Yes

risk of publication bias (Figure 4). Furthermore, we

used the Egger’s test to assess the reliability of our
funnel plot (t = −0.72, P = 0.493; 95%CI, −2.82 to
Unclear

Unclear

Unclear

1.48), and the results showed that there was no evi-

Yes
Yes

Yes
Yes
Yes
Yes
Yes

Yes

dence of publication bias.

Duncan and Earhart29
Wong-Yu and Mak25
Vergara-Diaz et al.27

Discussion
Conradsson et al.26
Rosenfeldt et al.22

de Bruin et al.28
Wallen et al.24
Geroin et al.19

This review showed that the mean difference

Tedla et al.23
Yang et al.21

Beck et al.20

between dual-task training and control groups sig-

nificantly favoured the former for single- and dual-
Study

task conditions, and that dual-task gait speed had a

8 Clinical Rehabilitation 00(0)

Figure 1.  Flow diagram outlining the article-selection process.

greater therapeutic effect compared with the speed
of a single task. The mean differences in gait speed
involving both single- and dual-task conditions
were 0.29 and 0.13  m/s, respectively, which
exceeded the pooled effect of exercise in
Parkinson’s disease (0.04–0.05 m/s), as previously
reported in two meta-analyses.38,39 A previous
study reported that the effect of dual-task training
on gait speed exceeded the minimum clinically sig-
nificant change (i.e. 0.05 m/s for gait speed) and
was usually substantial (i.e. 0.1 m/s).38 Furthermore,
it has been demonstrated that such a training effect
Li et al. 9

Figure 2.  Frost plot depicting the effect of dual-task training on (a) gait speed, (b) step length and stride length
and (c) cadence.
SD: standard deviation; Std. mean difference: standardized mean difference; CI: confidence interval; DT: dual-task.
10 Clinical Rehabilitation 00(0)
Figure 3.  Forest plot depicting the effect of dual-task training on (a) motor symptoms and (b) balance.
SD: standard deviation; Std. mean difference: standardized mean difference; CI: confidence interval; DT: dual task.
Figure 4.  Funnel plot of gait speed in dual-task
training versus control. Each point on the funnel plot
shows the standardized mean difference (SMD) for a
single study (x-axis), plotted against the standard error
(SE) of the standardized mean difference (y-axis).
is preserved at 3-week or 6-month follow-ups.25,34
These results are consistent with the preliminary
analysis of the DUALITY trial that demonstrated
that the effectiveness of a 6-week dual-task train-
ing programme was sustained for up to 12 weeks
after training.19 Furthermore, the cadence of such
studies showed a medium increased effect after
training compared with that of the control.
In our present meta-analysis, we found an
overall effect size of 0.56 in UPDRSIII, indicat-
ing large effects in favour of dual-task training.
Despite dual-task training only having a moder-
ate effect on balance function, this effect exhib-
ited large heterogeneity (I2 = 56%) primarily due
to one study conducting interventions during the
‘off’ phase of anti-parkinsonian medication, in
contrast to all other studies instead being con-
ducted during the corresponding ‘on’ phase.29
Additionally, methodological differences may
have also accounted for this heterogeneity, such
as from the types and durations of dual-task inter-
ventions. However, we found no significant
changes in step or stride lengths at post-interven-
tion, possibly due to a lack of customization of
the training modalities for improving these gait
parameters. The small sample sizes in some stud-
ies,21–23,27,28 heterogeneity of the dual-task para-
digm, and differences in assessment criteria may
have further affected the generalization of our
present results. Nevertheless, a significant
increase in stride length was observed in two
non-RCTs; these studies conducted a single
30-minutes session or three 30-minutes sessions,
and training effects were maintained at follow-
ups.31,34 Moreover, three non-RCTs reported
Li et al. 11
improvements in gait speed that occurred under a
single condition following 1 week, 3 weeks or
6 weeks of training,30,33,34 while one non-RCT
found that improvements were maintained at
3 weeks after multiple-task training.34 These find-
ings demonstrate that short-term dual-task train-
ing may increase the attention of gait in
individuals while performing additional tasks.
However, more RCTs with larger sample sizes
are still needed to further verify these findings.
Our meta-analysis had some limitations. First,
we only included trials published in the English
and Chinese language. Other languages should be
included for better global evaluations. Moreover,
there was no analysis on the effects associated
with different types of tasks and challenges asso-
ciated with these tasks in individuals with
Parkinson’s disease. Additionally, no subgroup
analysis was performed for similar dual-task types.
Other gait parameters, such as gait variability,
were not included in our present review. Finally, a
small number of studies provided weak evidence
in terms of the included methodologies, such as
unclear reporting of blinding conditions, inade-
quate allocation concealment in randomization
and/or a lack of a detailed description of analysis
of missing data.
Collectively, our present meta-analysis sug-
gests that evidence-based dual-task training may
be a safe and effective way to improve gait, motor
symptoms and balance in individuals with
Parkinson’s disease. These training modalities
may be integrated into clinical practice to
improve locomotion and to reduce the risk of
falls, and may also be generalized to individuals
with mild-to-moderate-stage Parkinson’s disease.
Furthermore, clinicians, therapists and health-
policy makers may be able to design individual-
ized dual-task exercises according to clinical
features. Future large-scale studies should be
conducted to identify sustained effects of dual-
task training at long-term follow-ups. Taken
together, our present findings may be helpful for
clinicians and patients to select appropriate meth-
ods and durations of dual-task training to further
optimize intervention programmes.
Clinical message
•• This review provides evidence that dual-
task training may be an effective method
for improving gait function, motor symp-
toms and balance in patients with
Parkinson’s disease.
Acknowledgements
We would like to thank Dr Meng Cao and Prof Xueqiang
Wang for their help and guidance in writing the article
and in performing data analyses.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship and/or publica-
tion of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship and/or publica-
tion of this article: This study was supported by the
following funding sources: the General Administration
of Sport of China Technology Services Project (grant
number: 2017B016); the Shanghai Key Lab of Human
Performance (Shanghai University of Sport; grant num-
ber: 11DZ2261100); Shanghai Science and Technology
Committee (grant number: 20DZ2300900).
Trial registration
PROSPERO 2018 CRD42018106732.
ORCID iD
Zhenlan Li https://orcid.org/0000-0002-3381-0961
Supplemental material
Supplemental material for this article is available online.
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