Gamified Dual-Task Training for Individuals with Parkinson Disease: An Exploratory Study on Feasibility, Safety, and Efficacy.

OBJECTIVES: The feasibility and safety of the use of neurorehabilitation technology (SMARTfit® Trainer system) by physical therapists in implementing a gamified physical-cognitive dual-task training (DTT) paradigm for individuals with Parkinson disease (IWPD) was examined. Additionally, the efficacy of this gamified DTT was compared to physical single-task training (STT), both of which were optimized using physio-motivational factors, on changes in motor and cognitive outcomes, and self-assessed disability in activities of daily living. METHODS: Using a cross-over study design, eight participants with mild-to-moderate idiopathic PD (including one with mild cognitive impairment) completed both training conditions (i.e., gamified DTT and STT). For each training condition, the participants attended 2-3 sessions per week over 8.8 weeks on average, with the total amount of training being equivalent to 24 1 h sessions. A washout period averaging 11.5 weeks was inserted between training conditions. STT consisted of task-oriented training involving the practice of functional tasks, whereas for gamified DTT, the same task-oriented training was implemented simultaneously with varied cognitive games using an interactive training system (SMARTfit®). Both training conditions were optimized through continual adaptation to ensure the use of challenging tasks and to provide autonomy support. Training hours, heart rate, and adverse events were measured to assess the feasibility and safety of the gamified DTT protocol. Motor and cognitive function as well as perceived disability were assessed before and after each training condition. RESULTS: Gamified DTT was feasible and safe for this cohort. Across participants, significant improvements were achieved in more outcome measures after gamified DTT than they were after STT. Individually, participants with specific demographic and clinical characteristics responded differently to the two training conditions. CONCLUSION: Physical therapists' utilization of technology with versatile hardware configurations and customizable software application selections was feasible and safe for implementing a tailor-made intervention and for adapting it in real-time to meet the individualized, evolving training needs of IWPD. Specifically in comparison to optimized STT, there was a preliminary signal of efficacy for gamified DTT in improving motor and cognitive function as well as perceived disability in IWPD.

Superiority of external attentional focus for motor performance and learning: Systematic reviews and meta-analyses.

Considerable literature on the role of attentional focus in motor performance and learning has accumulated for over two decades. We report the results of comprehensive meta-analyses that address the impact of an external focus (EF, on intended movement effects) versus internal focus (IF, on movements of body parts) of attention on the performance and learning of motor skills. Values of effect sizes (ES) from 73 studies with 1,824 participants and 40 studies with 1,274 participants were used for examining the effects of EF versus IF on behavioral outcomes of motor performance and learning (separately for retention and transfer phases) respectively. The EF condition was more effective than the IF condition for performance, Hedges' g value = 0.264 (95% CI [0.217, 0.310]), retention learning, Hedges' g value = 0.583 (95% CI [0.425, 0.741]), and transfer learning, Hedges' g value = 0.584 (95% CI [0.325, 0.842]). Multivariable metaregression analyses on behavioral measures further indicated that neither age group, health status, or skill level, nor their two-way interactions, moderated the ES differences between EF and IF in performance, retention, and transfer models (all p > .100). A secondary analysis on 12 studies with 216 participants that examined the effects of EF versus IF on electromyographic outcomes of motor performance also indicated that EF was associated with more efficient neuromuscular processing, Hedges' g value = 0.833 (95% CI [0.453, 1.213]). From nine studies with 272 participants, performance measured by behavioral outcomes was found to be more effective when a more distal, rather than proximal, EF was used, Hedges' g value = 0.224 (95% CI [0.019, 0.429]). Overall, the meta-analytic results are consistent with prior narrative reviews and indicate that an external focus is superior to an internal focus whether considering tests of motor performance or learning, and regardless of age, health condition, and level of skill expertise. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Choose your words wisely: Optimizing impacts on standardized performance testing.

BACKGROUND: The OPTIMAL theory of motor learning identifies motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (an external attentional focus, EF) factors that affect motor performance and learning [1]. One implication of this theory is that standardized clinical and laboratory assessments of physical capacity and motor performance that do not incorporate optimizing conditions may underestimate true maximal capabilities. The influence of "optimized" conditions on a clinical-applied test of balance control was examined with healthy participants. Given the motor performance benefits of optimized conditions predicted by the OPTIMAL theory, it was hypothesized that providing participants with information that induced EE, provided them with AS, and promoted their use of EF would reduce balance errors and postural sway. METHODS: We used as an exemplar assessment, the Balance Error Scoring System (BESS), and center-of-pressure (COP) velocity measurements of postural sway. Participants performed under two different conditions, separated by two days: an optimized (EE, AS, and EF) condition and a control ("neutral") condition, with sample-wide order counterbalancing. In each condition, participants performed three stances (double-leg, single-leg, and tandem) on two support surfaces (firm and foam). Stance order was participant-determined in the optimized condition and, for the control condition, yoked to a participant in the optimized condition. RESULTS: Participants committed fewer balance errors in the optimized condition than in the control condition (p < .001) and their resultant COP velocity in the optimized condition was lower than that in the control condition (p = .004). BESS scores were correlated with resultant COP velocity (r = .593, p < .001). SIGNIFICANCE: Our results demonstrated the impact of implementing optimized, as opposed to "neutral" control, conditions for better insight into balance capabilities in normal and challenging situations. Practitioners' roles in mediating test situations and using subtle wording to promote optimized performance may have consequential impacts on motor assessment outcomes.

Practice variability promotes an external focus of attention and enhances motor skill learning.

Variability in practice has been shown to enhance motor skill learning. Benefits of practice variability have been attributed to motor schema formation (variable versus constant practice), or more effortful information processing (random versus blocked practice). We hypothesized that, among other mechanisms, greater practice variability might promote an external focus of attention on the intended movement effect, while less variability would be more conducive to a less effective internal focus on body movements. In Experiment 1, the learning of a throwing task was enhanced by variable versus constant practice, and variable group participants reported focusing more on the distance to the target (external focus), while constant group participants focused more on their posture (internal focus). In Experiment 2, golf putting was learned more effectively with a random compared with a blocked practice schedule. Furthermore, random group learners reported using a more effective distal external focus (i.e., distance to the target) to a greater extent, whereas blocked group participants used a less effective proximal focus (i.e., putter) more often. While attentional focus was assessed through questionnaires in the first two experiments, learners in Experiment 3 were asked to report their current attentional focus at any time during practice. Again, the learning of a throwing task was more effective after random relative to blocked practice. Also, random practice learners reported using more external focus cues, while in blocked practice participants used more internal focus cues. The findings suggest that the attentional foci induced by different practice schedules might be at least partially responsible for the learning differences.

Onward and upward: Optimizing motor performance.

In the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016), three factors are postulated to facilitate motor performance and learning: Enhanced expectancies (EE) for performance, autonomy support (AS), and an external focus (EF) of attention. We examined whether EE, AS, and EF would have immediate performance benefits and whether implementing these factors consecutively would lead to incremental performance increases. Participants were assigned to the optimized or control groups and performed a maximal jump. After the first trial block (baseline), optimized group participants were provided different conditions on each of the following 3 blocks: (a) Positive social-comparative feedback (EE); (b) choice of figure on the ground from which to jump (AS); and (c) instructions to focus on a marker on their waist (EF). The order of conditions was counterbalanced. Control group participants performed all 4 blocks under the same (control) condition. The optimized group outperformed the control group on Blocks 2-4. Moreover, their jump height increased with each addition of another variable, whereas it did not change across blocks in the control group. Thus, EE, AS, and EF had additive or incremental benefits for performance. The findings corroborate the importance of key variables in the OPTIMAL theory for motor performance.