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[Physio Explained] Dual tasking in rehab: what, why, and how with Dr Mike Studer

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In this episode we discuss the topic of dual tasking. We explore: 

  • The definition of dual tasking 
  • How we can utilise dual tasking in sports, orthopaedic and return to work with our patients 
  • Dosage & delivery of dual tasking 
  • Dual tasking vs multitasking  

Want to learn more about dual tasking? Dr Mike Studer recently did a brilliant Masterclass with us called “Uniting Cognitive and Physical Fitness with Dual Tasking” where he goes into further depth on this topic. 

👉🏻 You can watch his class now with our 7-day free trial: https://physio.network/masterclass-studer1

Dr. Mike Studer, a physical therapist since 1991 and board-certified in neurologic PT since 1995, is an internationally recognized expert in rehabilitation, having spoken across all 50 U.S. states, 12 countries, and 4 continents. He teaches at Touro University and the University of Nevada Las Vegas and has been honored as Clinician of the Year by both the Neurologic and Geriatric Academies of the APTA. In 2020, he was named a Catherine Worthingham Fellow, the highest recognition in the field of physical therapy. Dr. Studer holds a trademark and patent pending in dual task rehabilitation, and has published extensively, including over 40 articles and 7 book chapters.  

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps! 

Our host is @James_Armstrong_Physio from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

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UNKNOWN:

Thank you.

SPEAKER_01:

We only become more tolerant of distractions when we ability to handle distractions when I've been around more of them, same as I can handle head rotations in VR recovery, same as I can handle repeated spinal flexion in orthopedic or persistent pain recovery.

SPEAKER_02:

Welcome to the PhysioExplain podcast. Today, we're thrilled to be joined by Mike Struder, a leading expert in motor control rehabilitation. Mike is a practicing physical therapist, adjunct professor at Oregon State University, and has received numerous honors for his work, including being named clinician of the year by the actor and being distinguished as a Catherine Worthingham Fellow in 2020. In this episode, we'll be discussing dual tasking in sports, orthopedics, and return to work. We'll explore how dual tasking can enhance rehabilitation and wellness, why being tolerant of distractions can improve our performance in sport and work, and how delivering dual tasking strategies helps automise motor skills for better outcomes. Mike will also share insights in how dual tasking works best when learners have autonomy, can see progress, and when the tasks are tailored to the individual. This is just the tip of the iceberg. Mike dives much deeper into these concepts in his masterclass that he's recorded with the Physio Network. And if you're eager to explore the science behind dual tasking in more depth and how you can unlock some of these actionable strategies for your practice, be sure to check out the free masterclass available in our seven-day trial. You'll also find the link in the show notes. Trust me, you will not want to miss it. Now, let's get into today's episode. I'm James Armstrong and this is Physio Explained. Mike, welcome back to the podcast.

SPEAKER_01:

Thankfully, here in this aspect of medicine, we have a very clear and consensus definition that dual tasking is the simultaneous performance of two tasks that can be performed separately and measured separately. So that is to say that the effort is not going toward one direction. For example, today, James, I'm pedaling a bicycle underneath me while I'm being interviewed on this podcast. That's not hypothetical. That's the reality. But my biking doesn't actually help me answer the questions better. And answering the questions doesn't help me bike better. It's dual tasking. They have to be separate entities.

SPEAKER_02:

So we've got this real distinction with no joined up in between. Okay, right. So when we talk about rehabilitation, as many of the people listening to the podcast are physiotherapists in different guises, how is it a healthy part of rehabilitation and wellness? And how does it help a of skill development and recovery and things like that.

SPEAKER_01:

So let's understand that many of the tasks that we do on a regular basis, dressing ourselves, walking, brushing teeth, and so on, are so well formulated in our brain that they're automatized. They are stored in the basal ganglia and the cerebellum, and they're what's known as a procedural memory. So in skill development for an athlete, we want those skills, shooting a free throw, dribbling a foot soccer ball, etc. We want those to be automatized so you don't have to think about them. And in rehabilitation, we want an individual recovering from stroke to be able to walk without thinking. So when we load the athlete or the recovering individual with a secondary unrelated distractor, we're helping to ensure that the areas of the brain that are supposed to be taking these things over are in fact the responsible areas in recovery, or in skill development by constraining your attention, pulling your attention someplace else so that you can't overthink about how to do the task.

SPEAKER_02:

So would you say that I'm right in thinking that we're taking away the conscious thought of certain motor skills and that skill acquisition?

SPEAKER_01:

Yes, in fact, because it's unhealthy for me to be a basketball player standing at the free throw line thinking about the angle of my wrist. Similarly, it would be unhealthy for me as a person recovering from stroke at 78 years old to think about, do I put the cane first and now my right foot and now my left foot? It's going to slow me down. It's going to make my movements very much more intentional and make it more likely that I will trip, fall or lose sequence. It's going to interfere with my ability to participate in either of those.

SPEAKER_02:

It's sort of taking away that overthinking that we sometimes talk about, isn't it? Yes, exactly. Many people listen to this who've played sport know that, well, I'm going to talk to all the golfers out there straight away. Now you're talking about the yips already. Yeah, exactly. Exactly. Okay. I've got a million and one questions already running through my mind because this is really quite thought provoking. So how are we, that toleration of distraction in sports and work? You've touched on it already there, Mike. Can you tell us a little bit more about that being tolerant of those distractions?

SPEAKER_01:

It's a good follow-up question because in fact, we only become more tolerant of distractions when we expose ourselves to those distractions in a systematic fashion. And it's not unlike vestibular rehabilitation or graded motor exposure in pain neuroscience, where we give the individual a systematic and titrated and tolerable dosage so that they can habituate. So I'm only going to be able to tolerate what I've been exposed to. I gain my ability to handle distractions when I've been around Okay. I suppose that's if you throw someone in the deep end,

SPEAKER_02:

they're just going to fail as well. So then if we talk about motivating patients.

SPEAKER_01:

Right. So we want it to be a dosage that is tolerable for their capacities. And as we'll talk about later, we also want them to have a voice in selecting the dosage to have a degree of autonomy. Absolutely.

SPEAKER_02:

Yeah, definitely. So they become part of that journey. When we talk about delivery of dual tasking and successfully automatizing this, how can we go about that with motor skills and making sure that they can be accomplished?

SPEAKER_01:

This has a developing science to it that's well-established now, but it's not perfect. So you begin by assessing and objectively measuring an individual's single task performance. Two-minute- walk test, six minute walk test, timed up and go, a shuttle run, and any other sport performance that you could have. How quickly can you dribble the ball down the complete length of the pitch, etc. You can take any single task measurement. Now you take a secondary distractor measurement. How many rugby teams can you name in 20 seconds? How many times can you subtract by serial sevens from 101? How many different bird varieties can you name, okay? So we take any other single task measurement. Now we're going to combine the two and see what the participant, the subject, or the patient's difference is when they're combined, and we call that a dual task cost. Now we see, oh wow, it took you eight seconds longer to get down the pitch dribbling the soccer ball while you were also trying to name rugby teams. Well, that means you are definitely experiencing a cost that it's not well automatized. So now we know we have to deliver a dosage of that to shore up your capacities. And we'll also know when we've improved you. So the delivery comes in number one, measuring to determine you've got a cost. And number two, let's put it in the sports specific context so that we actually distract you at your work or in your mobility related ADLs or in your sport with one of the modes of distractors that is borrowing enough from you. So far, I just talked about naming things. So those would be cognitive distractors. We can also deliver dosage in visual distractors. Tell us when we're holding up this cue card or this number one or your coach is holding up this sign. Auditory distractors or even manual distractors. Can you walk while you're pulling a credit card out of your wallet? So we deliver those types of dosages. in accordance with what the person needs in the context that they need it.

SPEAKER_00:

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SPEAKER_02:

It's really interesting, actually, Mike. You're making me think back to some outcome measures that I've used in the past, which is a mini-best, I think, if I'm right in thinking, which has exactly this in it. But so many times, you find patients really struggle. And the first thing I'm thinking is, they've not experienced that necessarily in their rehabilitation, and we're then challenging them in a test. That's interesting.

SPEAKER_01:

Yes, and you're exactly right. We unfortunately don't utilize dual task across Sport, performance, rehabilitation, and workplace, even though all of those experience it in the natural expression, we don't do it in rehabilitation. So people are down-trained to it. They're surprised by it. It feels awkward to them. And we definitely need to get better at it. And one thing I'll say about that when you reference the many best is that we need to make certain that we're not just doing mathematics or subtraction with everyone. Because some people bring a degree of fear, IQ I can't do this. I've never been able to do this. I can't do it in solitude. Why would you ask me to divide my attention toward that? Yeah, absolutely.

SPEAKER_02:

And I suppose what's really ringing true for me here is if we go back to why are we doing this in the first place, not just because it's part of battery of tests to look at balance, etc. Actually, we're looking at that automatization of a task and how we identify whether it's truly automatized. Right.

SPEAKER_01:

And if you were to put it very, very succinctly, you just want to know how stable is their performance in this task, or can I manipulate it by withdrawing their attention? And that's it. Is the task stable? You might be ready to return to sport after concussion, return to work after concussion or stroke. You might be able to return to driving after stroke. You might be able to elevate to the next level of game if you can demonstrate this in skill performance. So how stable is it? You don't want an opposing crowd to be able to distract your player when they're taking a penalty kick. So in practice, can you try to distract them, expose them to distractions and see how stable their penalty kick performance is under the duress of distraction?

SPEAKER_02:

Yeah, I thought straight away of thinking of penalty kicks being from England, it's quite poignant And also this applies, I'm thinking as well, to things like ACL rehabilitation, where you've lost a lot of potential proprioception and timeout. This is really key, isn't it?

SPEAKER_01:

It is, because James, you mentioned the yips just a few moments ago, where I brought the term up and you were referring to it. Imagine there are some persons recovering from anterior cruciate ligament who become ultimately too internally focused on the affected leg and they develop a functional neurologic disorder They develop an inability to communicate with the leg when they're thinking about it. And we have to actually draw their attention away from that so that they can, in fact, function at their optimal level.

SPEAKER_02:

Absolutely. Yeah. And it fits so perfectly with this sport. But also, as you say, it's about our ADLs. It's about whether we're walking the dog. It's about whether we're driving, working in a skill set that we might have in a manufacturing plant, whatever it might be. These are all really very applicable.

SPEAKER_01:

Yes, we frequently dual task. There are fewer times that we single task than we dual task. So dual task is very prevalent, but it does beg the question because we could have a couple of listeners out there, James, wondering if dual task is healthy, shouldn't we also load our patients in a multi-task manner? And in fact, the answer there is no. So learning improves when we subtract cognition away and load with a dual task but if we compel someone to pay attention to more than two tasks and we multitask all we're asking them to do is get better at task switching and while paying attention to this plate or this plate doesn't help you learn the ability to manage the plates it just gets you better at task switching so it's a totally separate task that's being developed but you're not learning either one of the tasks better

SPEAKER_02:

and again that comes back to the right at the beginning of this podcast where you introduced that. Why are we doing this? And multitasking is just totally a different thing altogether. It doesn't fit.

SPEAKER_01:

Yes. It's a task between alternating attention and divided attention. And that's what it comes down to when we talk about it in the sector.

SPEAKER_02:

Okay. So we're then moving on to delivering dual tasking, particularly with the person at the center of this. So how do we go about that real clinical takeaway here for, I'm sure?

SPEAKER_01:

Yes, and the good fortune is we've mentioned this now a couple of times, but let's dive into it a little bit more. So let's understand the person because ultimately rehabilitation is moving toward precision medicine and person-specific medicine. So James, let's do an experiment right now that you and I didn't plan, okay? All right. So James, what is your favorite sport? Rugby. Rugby is your favorite sport. So again, we could come up with the example wherein I could either say, James, while you're doing the 60 second sit to stand test or you're doing the shuttle run test, if I were to give you an auditory distractor, I name rugby teams when you get back from the shuttle run and I'm actually naming them while you're shuttle running. or your sit to standing, you have to, upon completion, give me all the rugby teams back. That's an auditory distractor. But it would be a cognitive distractor if I say, James, while you're doing it, name all the rugby teams that you can. Okay? Okay. Yeah. Now, in fact, we could do it as a manual distractor. I give you cards, playing cards of rugby players and you sort them while you're doing your 60 second sit to stand. You sort them according to either who is older or who's on the same team. And you have the All Blacks and you sorted three people from the All Blacks over to this team and you were given seven cards. So I could give you a manual distractor, an auditory distractor, or a cognitive distractor. And finally, while you're doing your sit to stands, I could actually have rugby players flash up on my laptop screen. And while you're doing your sit to stands, you have to at the end of it say, Name as many rugby players as you saw appear on the screen. That would be practical. It would be engaging. You would find it fun. It has some trivia basis to it. And for some people, they would redouble their sit-to-stand performance while they're doing it. That would be a dual task effect. Some people, they would slow their sit-to-stands down because they're trying to look at that and they say, I don't know what uniform that is or what team that is. And so we would find out how resilient... or stable your shuttle run or your sit to stand it's.

SPEAKER_02:

So to credit Daniel Kahneman for the thinking fast and slow is what I was thinking of just a second ago there, Mike. So yeah, and that kind of fits this, doesn't it, a bit?

SPEAKER_01:

It does. And we want to see, you know, if your active mode network, your thinking fast network can be easily overwhelmed, then it might be challenging for you to participate in the penalty kick, to take that inbounds pass when there's just a couple of seconds left. Maybe we've got another player who's more well suited to handle that. And And maybe the person recovering from stroke needs to manage their environment so that there's not a lot of inherent distractions while they're relearning how to walk. So that could be one way to manage the environment while they are rehabilitating.

SPEAKER_02:

Brilliant, Mike. This is such a thought-provoking topic and an awful lot more to go into. And I think what you've really honed in today that people could take away is this is something that should be incorporated into rehabilitation, not just tested. And knowing why you're doing it is really, really key, which I know you cover all of this much more in the masterclass.

SPEAKER_01:

Yes. But James, thanks for the opportunity to allow me to elaborate on this in our efforts today.

SPEAKER_02:

Absolutely. Thank you so much for your time, Mike. And for those listening who I'm sure want to find out more about this and how to use it in practice more than we've already covered today, a reminder that you want to learn about dual tasking and how you put it into rehabilitation, then do check out Mike's masterclass. It's done for the Physio Network and will We'll put some links in the show notes below. Mike, thank you ever so much for your time again.

SPEAKER_01:

Take care, James. Thanks again. Cheers and have a great day.