Risk of fall in female Saudi students who engage in cognitive-motor dual tasks- A Cross Sectional Study

doi:10.21203/rs.3.rs-2727146/v1

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Risk of fall in female Saudi students who engage in cognitive-motor dual tasks- A Cross Sectional Study

https://doi.org/10.21203/rs.3.rs-2727146/v1

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Background: Dual tasking (DT) requires individuals to carry out two actions simultaneously, comparable to how the brain can perform a cognitive function while the body is in motion, which eventually enhances human balance.

Objective: To examine and compare the impact of DT on the risk of falling (ROF) among Saudi female students enrolled in the literary and scientific faculties.

Method: A cross-sectional design was used. 120 female students consented to this study after 150 were invited. Specialization led to the formation of the scientific (SG, 86) and literary (LG, 34) groups. All participants, aged 18 to 25, had a normal BMI and normal cognitive and balance skills. Using the Biodex balancing system, ROF during balance alone (no DT) and with DT (motor and two types of cognitive tasks) were assessed. ROF was compared within and between groups using paired and unpaired T-tests, respectively. Mann-Whitney compared the two groups throughout the DT. The level of significant was considered at P=0.05.

Results: There was no significant difference in ROF in SG (P 0.05) between the performance with and without dual tasking, contrary, LG demonstrated a significant difference (P=0.05) for the same tests. In addition, the only time there was a significant difference between the two groups was when they performed DT.

Conclusion: SG students are better capable than LG students in maintaining balance and resisting the ROF during DT. This study's findings may pave the way for improved interventions to reduce fall risk and improve balance during neurorehabilitation.

Dual tasks

risk of fall

balance

cognition

and Biodex system

Dual tasking (DT) requires individuals to perform two tasks concurrently, comparable to the brain's ability to undertake a cognitive activity while walking. The investigation revealed a relationship between the central nervous system and movement, this link discussed the brain's participation in cognitive activities when walking [1, 2]. During DT, the prefrontal cortex and anterior cingulate cortex are two areas of the brain that are generally engaged. Training these parts of the brain may enhance a person's balance and reduce the likelihood of their falling [3]. The relationship between cognitive decline or deterioration and slowness of motion, including gait velocity, cadence, step and stride duration, was identified by researchers. Alzheimer's disease patients walk slower than individuals with mild cognitive impairment, who walk slower than those with cognitive health. There is a relationship between cognitive function and walking speed. Poor mental executive function has still been associated to falls [4].

It has been demonstrated that a person's capacity to maintain balance decreases when performing two or more tasks simultaneously [5–9]. Findings showed that when individuals walked while conversing, they either stopped walking or required more time to complete their gait task [10]. Walking is a task that involves a high level of physical mobility, as well as cognitive flexibility to plan and execute movement [11]. DT increases the stimulation of movement-controlling areas in the brain, activating the release of neurotransmitters that increase the speed and adequacy of brain cells, particularly in the frontal lobe, consequently improving cognitive and motor performance [12]. In addition, cognitive-motor DT training enhanced functional performance greater than single-task training [13, 14]. In several studies comparing moderate cognitive impairment to severe cognitive impairment, researchers assessed the elderly's balance and risk of falling. There was a correlation between higher risk of falling and severe cognitive impairment [15, 16].

In the Kingdom of Saudi Arabia, there are two categories of higher education institutions: literary colleges (Sharia and arts) and scientific colleges (medicine and science). More than half of the roughly one million university and college students in Saudi Arabia are female.

Because of different educational institutions specialize in a variety of fields, the curriculum for the educational programs that are made available by these institutions is organized differently. The theoretical portion of higher education places a distinct emphasis on learning in contrast to the more hands-on, practical scientific portion of higher education. It was obvious that courses at scientific practical colleges required frequent movement and the execution of numerous tasks simultaneously, allowing students to participate in multiple cognitive processes while doing physical activities (dual task). However, very few researches have examined how the type & nature of education influences the balance of students. These sorts of investigations are quite rare. In addition, no previous researches in Saudi Arabia have examined the relationship between performing two tasks simultaneously and the type or nature of students’ study, which demands both mental and physical abilities, and the risk of falling or the capacity to maintain balance while performing both tasks. This paper aims to investigate the impact of DT on balance and the risk of falls among Saudi female science and literature students. Furthermore, to determine if there is any relationship between a student's study style and the risk of falling while carrying out a dual task.

Subjects.

An announcement of a research was given to 150 female students on a campus where only women teach at the University of Umm Al-Qura- Saudi Arabia. This notice was accompanied by an invitation letter and a proposal that described the research and its purpose, the necessity for participants to be present and the prerequisites for participation, as well as the significance of their attendance and involvement. 120 (80%) of the 150 participants who consented to participate in the study were emailed the consent form. There were 86 female students enrolled at scientific colleges and 34 at literary colleges. For research purposes, the first group was known as the scientific group (SG), whereas the second was known as the literary group (LG) (Fig. 1).

Any healthy female student currently enrolled in courses at the University of Umm Al-Qura was eligible to participate in the study. Students who exhibited any cognitive, visual, auditory, neurological, or balance impairments were excluded for participation. The Biomedical Research Ethics Committee for scientific research of Umm Al-Qura University provided their approval for this study, HAPO-02-K-012-2022-11.

Instruments

The Biodex balancing system (230VAC #950 − 302) was utilized in order to calculate the fall risk index both with and without the execution of dual-tasking, and each test consisted of three separate trials. The system consists of a thorough fall risk screening, conditioning program, and procedure to help the examiner in recording a fall risk. By comparing balance test results to age-dependent normative data, the Balance System SD might identify a possible issue in two minutes. The protocol for fall risk assessment conforms to American Geriatrics Guidelines [17].

Procedure

The participants were instructed to remove their shoes, socks, and any other items of clothing that may influence the results of the risk of falling test. Everyone was given extremely detailed instructions on the procedure. After instructing subjects to stand on the Biodex with their feet positioned at (LTD6, RTD16, Angle 10 degrees), their potential for falling was assessed (without the use of DT). In addition, they were instructed to maintain the same center of gravity during all three trials. After then, the mean was calculated (Fig. 2).

The participant retook the examination while engaging in a dual task that included a cognitive task (mathematical operations and memory functions). A laptop was placed on front of each participant, and while their COG was being monitored by the Biodex system, a PowerPoint slideshow with cognitive and memory questions was shown. The slides were timed, and the reaction time for each question was set at 1.75 seconds. The cognitive examination consisted of six simple fundamental arithmetic operations( like the sum of 1 and 3) and each of the six additional questions on colors required the participant to identify the displayed words by their color rather than by the word's name as it appeared in the text (Fig. 3).

After completing 3 separate trials, the mean and average were calculated. In a discussion forum, one of the researchers verifies the accuracy of the questions' responses. A second researcher supervised the laptop with the cognitive and memory test. Both researchers guaranteed that the patient did not move feet or hands during the examination.

Statistical analysis

The results of the statistical analysis for the scientific group (SG) and the literary group (LG) with a normal BMI were represented as the mean (M) and standard deviation (SD). Levene's test revealed that the ROF of both groups were identical when assessed with and without the DT. A paired T-test was utilized to compare the ROF within each group. An unpaired T-test was utilized to compare ROF between the two groups. During dual tasks, the Mann-Whitney test was also used to analyze the median differences in memory and mathematical operations between the two groups.

Participating in this study were a total of one hundred and twenty Saudi female students. In all, there were 86 students enrolled in scientific group (SG), & another 34 students were enrolled in literal group (LG). There was no significant difference between the two groups in terms of age, weight, height, or body mass index (BMI). In addition, there were no significant differences in the ROF between the two groups before they did DT (P > 0.05). Table 1 shows the collected demographic data.

Table 1

Demographic characteristics of all subjects; data were collected from 120 females
Variables	SG Mean ±SD	LG Mean ±SD	T value	P value
Age (Yrs.)	19.9 ± 1.48	20.4 ± 1.69	1.235	0.09
Weight (Kg)	59.4 ± 11.12	60.7 ± 13.62	0.409	1.20
Height (Cm)	157.2 ± 6.38	156.6 ± 6.15	1.430	0.12
BMI	20.9 ± 2.04	21.9 ± 1.93	4.469	0.13

BMI: Body mass index; SD: Standard deviation, SG: Scientific group, LG: literary group, Yrs.: Years, Kg: Kilogram, Cm: Centimeter.

The findings indicated no significant difference in ROF between using DT and not using it at SG (P > 0.05). At LG, on the other hand, a significant difference in ROF was recorded between having DT and not having it (P < 0.05) (Table 2).

Table 2

A comparison of ROF between groups of normal BMI with and without doing DT
Variables	SG (M ± SD)	LG (M ± SD)	Mean of differences	SEM	T	P-value.
ROF (without DT)	1.45 ± 0.81	1.62 \(\pm\) 0.86	0.26	0.02	10.61	0.06
ROF (with DT)	1.71 \(\pm\) 0.74	2.68 \(\pm\) 0.85	0.96	0.16	5.745	0.0061*

ROF: Risk of fall; DT: Dual task; SG: Scientific group, LG: literary group, *: Significant.

In addition, the findings demonstrated that the risk of falling during DT was noticeably higher in LG when compared to SG. The mean differences between the two groups in terms of DT performance are shown in Fig. 4 (P = 0.006).

The median SG differences for memory and math scores were five and four, respectively. In comparison, the LG had median scores of 3.50 and 2.33 for memory and math tasks, respectively There were significant differences between the two groups (P > 0.05) (Table 3).

Table 3

A comparison of memory and mathematics tasks between groups of normal BMI with and without doing dual tasks.
Variables	SG Median	LG Median	Median differences	Mann-Whitney U	P-value.
Memory Score	5.00	3.50	1.50	323	0.0001*
Mathematics Score	4.00	2.33	1.67	434.5	0.0001*

SG: Scientific group, LG: literary group, *: Significant.

The median scores differences (between both groups) of mathematics task (1.670) was higher than the median scores differences of memory task (1.50) (Fig. 5).

This study aimed to investigate the effects of doing dual tasks on the risk of falling (ROF) among Saudi female students in the literary and scientific faculties. Furthermore, to determine if there is any relationship between a student's study style and the risk of falling while carrying out a dual task. The findings showed that ROF mean values differed depending on whether DT was performed or not at SG. However, the observed difference was not statistically significant (P > 0.05), indicating that scientific college students may have superior balance and be able to avoid falling when juggling several duties (dual tasks).

Since, the fact that students in scientific colleges have better environments for moving around and completing their work than students in other colleges, the response chosen depends not only on the characteristics of the external postural displacement, but also on the individual's expectations, goals, and prior experiences. While cues were being employed, all motions were executed at the same speed, and the platform's stability gradually decreased. The work into brain mapping has mostly focused on identifying activity fluctuations [18–20].

The current study providing a statistically significant difference (P 0.055) between the incidence of LG student falls without and during the performance of DT. This may be understood to suggest that even if the LG has good balance because they do not multitask (not doing dual tasks), the chance of falling would increase if another activity or task was added (dual tasks). This finding may be a result of the fact that when only one task was done (rather than two), the emphasis was only on balance, and participants acquired expertise in this area. That was supported by the current results as no significant difference in the probability of ROF before dual task between the two groups (P = 0.06), since the balance was the sole task assigned, when a participant is focusing on only one task, brain activity increases. This enhances the probability that the person will not fall and assists them in maintaining proper posture [21, 22].

In contrast, when participants conducted dual tasks, the focus was on both balance and the operations. Every conventional dual-task methodological model has employed either mathematical operation or memory while the participant performed a motor activity, resulting in a minor drop in one or both activities. According to the findings, the physical and/or cognitive performance of the individuals was much poorer than anticipated. Researchers have determined that an increase in cognitive load while doing a physical activity leads in an increase in cortical inhibition and a concomitant increase in reaction time [22].

This study showed significant difference in ROF between SG and LG when executing DT tasks (P = 0.0061). This indicates that the SG performed well throughout dual tasks and were able to maintain their balance with good memory and mathematical results than LG. Significant differences (P < 0.05) in both memory and math scores between the two groups (SG and LG) were also recorded. However, the difference in mathematics (1.67) results between the two groups was considerably greater than the difference in memory scores (1.50). This study revealed that LG did slightly better on memory questions than on mathematics issues. However, the ROF was much higher than expected in this group each time a math question was asked but not answered (combination of balance and memory performed better than mathematics in LG). This could be attributed to the fact of sway velocity reduction during the dual-task condition, researchers noticed a decline in balance when cognitive activities were conducted simultaneously & slight decrease in one or both measures throughout the completion of two tasks [23–26].

In addition, unlike modules taught at literacy colleges, modules taught in scientific colleges include mathematical operations. It was clear that those majoring in science and technology may be better able to focus on two tasks simultaneously than students majoring in arts and humanities, such as maintaining their balance, memorizing mathematical procedures, or doing mathematical operations.

The management of the body's sway and the brain's activities are not two separate systems [27], so the development of postural control may have been influenced by the environment. Less than one-third of the study participants were able to divide their attention between keeping their balance and doing the given task. This supports previous studies indicating that a subject's perception of balance may be enhanced by focusing on an external stimulus, such as a cognitive task, as well as combining cognitive training with regular motor training is the best technique for ensuring patients' autonomy in their daily motor tasks, & lowering the risk of falling and its consequences [28, 29].

Other investigations discovered the "posture-first" concept, which says that maintaining one's posture while simultaneously performing two activities involves a large amount of concentration; hence, balance control should take priority [30–32]. The brain is like to a muscle; just as a muscle must be exercised and utilized in to become strong, so too must the brain be exercised and utilized in order to achieve its greatest potential in terms of acting abilities. As a result, a brain that has been completely disregarded and not provided with opportunities for exercise may function poorly in a variety of circumstances [32].

One of the study's major limitations was that all of the subjects were female. This was linked to the Saudi Arabian educational system's requirement for gender separation in classes. Even with this limitation, applying the findings of this study to a larger population should not be too difficult. In addition, the implications of this study's findings potentially extend to a range of other fields. To evaluate the efficacy of perceptual-cognitive training interventions, for instance, a range of perceptual-cognitive training interventions may be conducted with professional athletes, surgery physicians, and drivers' license holders.

It was concluded that students with a better ability to maintain balance and resist the risk of falling while engaging in motor-cognitive activities (dual task) had been exposed to a greater number of scientific modules, critical and in-depth thinking, and complicated issues throughout their education. The results were compared to those of students who were not forced to complete as many science courses. This is because solving these kinds of challenges may allow you to perform many tasks simultaneously.

Ethics approval and consent to participate

The ethical approval for this study was provided from the Biomedical Research Ethics Committee at the Umm-Al-Qura University-Saudi Arabia (#XRPD091122, November 28, 2022). All participants included in this study provided informed written consent before the start of the participation. Confirming that all methods were carried out in accordance with relevant guidelines and regulations (declaration of Helsinki).

Consent for publication

Not applicable

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Competing interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors’ contributions

HM and SA developed the study's concept. HM was responsible for collecting and analysing data. SA produced the initial version of the manuscript, while HM and SA reviewed it for significant intellectual content. All authors reviewed and approved the final manuscript version.

Acknowledgements

The authors would like to express his gratitude to all of the students who contributed to this study.

Authors’ information.

Hayam M Mahmoud

Professor of Physical therapy for Neurology - Umm al-Qura university-Saudi Arabia; Cairo University, Egypt.

Salem F. Alatawi^⁎

Associate professor of neurorehabilitation

Department of Physical therapy

Faculty of Applied Medical Sciences

University of Tabuk

Tabuk City

Kingdom of Saudi Arabia

Tel: 00966144563434

Email: [email protected]

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No competing interests reported.

SupplementaryfileRawdatafromparticipantdatacollectingabouttheriskoffallswithandwithoutdualtasking..xlsx

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Risk of fall in female Saudi students who engage in cognitive-motor dual tasks- A Cross Sectional Study

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