This study was supported by grants from the National Natural Science Foundation of China (No. 81804004, 81902281), China Postdoctoral Science Foundation (No. 2018M643207), Shenzhen Municipal Health Commission Project (No. SZBC2018005), Shenzhen Science and Technology Project (No. JCYJ20160428174825490), the General Guidance Program of Guangzhou Municipal Health and Family Planning (No. 20211A010079, 20211A011106), Guangzhou and University Foundation (No. 202102010100), Guangzhou Medical University Foundation (No. PX-66221494), Key Laboratory of Guangdong Higher Education Institutes&#160; [Grant Number: 2021KSYS009] and Guangdong Province Department of Education [Grant Number: 2021ZDZX2063].

This project was approved by the Medical Ethics Association of the Fifth Affiliated Hospital of Guangzhou Medical University (No. KY01-2020-08-06) and has been registered at the China Clinical Trial Registration Center (No. ChiCTR2000036514). Informed consent was obtained from patients for using their data in this study.
1. Recruitment
<ol>
	<li>Recruit stroke patients with stable conditions as confirmed by imaging examination-diagnosis conforms to the diagnostic criteria of...

<ol>
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H., Chen, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neurobiology+of+stroke:+Research+progress+and+perspectives.">Neurobiology of stroke: Research progress and perspectives.</a> Progress In Neurobiology. 163-164, 1-4 (2018).</li><li>Maratos, M., Huynh, L., Tan, J., Lui, J., Jarus, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Picture+this:+Exploring+the+lived+experience+of+high-functioning+stroke+survivors+using+photovoice.">Picture this: Exploring the lived experience of high-functioning stroke survivors using photovoice.</a> Qualitative Health Research. 26 (8), 1055-1066 (2016).</li><li>Platz, T., Prass, K., Denzler, P., Bock, S., Mauritz, K. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Testing+a+motor+performance+series+and+a+kinematic+motion+analysis+as+measures+of+performance+in+high-functioning+stroke+patients:+reliability,+validity,+and+responsiveness+to+therapeutic+intervention.">Testing a motor performance series and a kinematic motion analysis as measures of performance in high-functioning stroke patients: reliability, validity, and responsiveness to therapeutic intervention.</a> Archives of Physical Medicine and Rehabilitation. 80 (3), 270-277 (1999).</li><li>Trzepacz, P. T., Hochstetler, H., Wang, S., Walker, B., Saykin, A. 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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Relationship+between+dual-task+gait+speed+and+walking+activity+poststroke.">Relationship between dual-task gait speed and walking activity poststroke.</a> Stroke. 49 (5), 1296-1298 (2018).</li><li>Liu, Y. -. C., Yang, Y. -. R., Tsai, Y. -. A., Wang, R. -. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cognitive+and+motor+dual+task+gait+training+improve+dual+task+gait+performance+after+stroke+-+A+randomized+controlled+pilot+trial.">Cognitive and motor dual task gait training improve dual task gait performance after stroke - A randomized controlled pilot trial.</a> Scientific Reports. 7 (1), 4070 (2017).</li><li>Manaf, H., Justine, M., Ting, G. H., Latiff, L. 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M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Half+a+century+of+research+on+the+Stroop+effect:+An+integrative+review.">Half a century of research on the Stroop effect: An integrative review.</a> Psychological Bulletin. 109 (2), 163-203 (1991).</li><li>Su, M., Wang, R., Dong, Z., Zhao, D., Yu, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Decline+in+attentional+inhibition+among+migraine+patients:+An+event-related+potential+study+using+the+Stroop+task.">Decline in attentional inhibition among migraine patients: An event-related potential study using the Stroop task.</a> The Journal of Headache and Pain. 22 (1), 34 (2021).</li><li>Tsang, C. S. L., Chong, D. Y. K., Pang, M. Y. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cognitive-motor+interference+in+walking+after+stroke:+test-retest+reliability+and+validity+of+dual-task+walking+assessments.">Cognitive-motor interference in walking after stroke: test-retest reliability and validity of dual-task walking assessments.</a> Clinical Rehabilitation. 33 (6), 1066-1078 (2019).</li><li>Bai, Q., Hu, J., Zhang, L. J., Chen, Y., Zhang, Y. H., Wang, X. C., Chi, L. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Application+value+of+Stroop+test+in+the+evaluation+of+cognitive+function+in+asymptomatic+cerebral+infarction.">Application value of Stroop test in the evaluation of cognitive function in asymptomatic cerebral infarction.</a> China Journal of Alzheimer's Disease and Related Disorders. 4 (4), 269-274 (2021).</li><li>Pandian, S., Arya, K. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stroke-related+motor+outcome+measures:+Do+they+quantify+the+neurophysiological+aspects+of+upper+extremity+recovery.">Stroke-related motor outcome measures: Do they quantify the neurophysiological aspects of upper extremity recovery.</a> Journal of Bodywork and Movement Therapies. 18 (3), 412-423 (2014).</li><li>Albert, M. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+simple+test+of+visual+neglect.">A simple test of visual neglect.</a> Neurology. 23 (6), 658-664 (1973).</li><li>Nasreddine, Z. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Montreal+Cognitive+Assessment,+MoCA:+A+brief+screening+tool+for+mild+cognitive+impairment.">The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment.</a> Journal of the American Geriatrics Society. 53 (4), 695-699 (2005).</li><li>Morris, J. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Clinical+Dementia+Rating+(CDR):+Current+version+and+scoring+rules.">The Clinical Dementia Rating (CDR): Current version and scoring rules.</a> Neurology. 43 (11), 2412-2414 (1993).</li><li>Sullivan, K. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fugl-Meyer+assessment+of+sensorimotor+function+after+stroke:+Standardized+training+procedure+for+clinical+practice+and+clinical+trials.">Fugl-Meyer assessment of sensorimotor function after stroke: Standardized training procedure for clinical practice and clinical trials.</a> Stroke. 42 (2), 427-432 (2011).</li><li>Sanford, J., Moreland, J., Swanson, L. R., Stratford, P. W., Gowland, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+the+Fugl-Meyer+assessment+for+testing+motor+performance+in+patients+following+stroke.">Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke.</a> Physical Therapy. 73 (7), 447-454 (1993).</li><li>Downs, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Berg+Balance+Scale.">The Berg Balance Scale.</a> Journal of Physiotherapy. 61 (1), 46 (2015).</li><li>Blum, L., Korner-Bitensky, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Usefulness+of+the+Berg+Balance+Scale+in+stroke+rehabilitation:+A+systematic+review.">Usefulness of the Berg Balance Scale in stroke rehabilitation: A systematic review.</a> Physical Therapy. 88 (5), 559-566 (2008).</li><li>El Said, S. M. S., Adly, N. N., Abdul-Rahman, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Executive+function+and+physical+function+among+community-dwelling+Egyptian+older+adults.">Executive function and physical function among community-dwelling Egyptian older adults.</a> Journal of Alzheimer's Disease. 80 (4), 1583-1589 (2021).</li><li>Al-Yahya, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prefrontal+cortex+activation+while+walking+under+dual-task+conditions+in+stroke:+A+multimodal+imaging+study.">Prefrontal cortex activation while walking under dual-task conditions in stroke: A multimodal imaging study.</a> Neurorehabilitation and Neural Repair. 30 (6), 591-599 (2016).</li><li>Matjacic, Z., Zadravec, M., Olensek, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Feasibility+of+robot-based+perturbed-balance+training+during+treadmill+walking+in+a+high-functioning+chronic+stroke+subject:+A+case-control+study.">Feasibility of robot-based perturbed-balance training during treadmill walking in a high-functioning chronic stroke subject: A case-control study.</a> Journal of Neuroengineering and Rehabilitation. 15 (1), 32 (2018).</li></ol>

In our study, the results of the routine clinical cognitive assessment scales for the high-functioning stroke patient did not show any significant cognitive deficits. However, these assessment scales might show a ceiling effect and be less sensitive for identifying the mild cognitive deficits of high-functioning stroke patients. Hence, this protocol further selected ACC and RT in dual-task assessment based on the Stroop paradigm as major indicators to identify the cognitive deficits of high-functioning stroke patients. T...

Stroke is the leading cause of disability in humans1 and can cause varying degrees of motor, cognitive, emotional, and other functional deficits2. Some stroke patients with better prognosis and only slight functional defects show greater functional autonomy in daily activities, but the functional state of their disability may not be sufficient to support their return to work or previous activities. These patients are referred to as high-functioning stroke patients3,4. Due to their minor functional deficits, it is hard to identify their dysfunctions, especially in terms of cognitive functions, through the general assessment of function scales, such as the Montreal cognitive assessment (MoCA)5 and clinical dementia rating (CDR)6, which have a ceiling effect and poor sensitivity for identifying mild functional defects in high-functioning stroke patients. Therefore, it is necessary to develop objective and simple methods to identify cognitive dysfunction in high-functioning stroke patients.
In recent years, the advantages of the dual-task paradigm in assessment and training have gradually become valued7,8. For example, patients may perform normally on simple cognitive single tasks (e.g., calculation) but show varying degrees of cognitive decline when additional tasks are added9,10 (e.g., walking while counting). Manaf et al. found that stroke patients often use compensatory strategies when performing cognitive-motor dual tasks, such as maintaining stability by sacrificing cognitive task performance11. Therefore, the dual-task assessment may have advantages in identifying cognitive deficits in patients with high-functioning stroke. On the one hand, the content of the dual-task assessment is closer to daily life than a single task, such as walking while observing the surrounding environment or talking and calling. In previous studies, the walking + naming task and walking + crossing obstacles task were designed to simulate walking in real environments12.
On the other hand, the executive ability in dual tasks has a close relationship with divided attention (belonging to the category of advanced cognitive function)13. Divided attention is the ability to handle multiple tasks simultaneously and allocate attention to two or more tasks14. This cognitive skill is of great significance to improve the efficiency of daily activities. Therefore, the results of the dual-task assessment can be used for reflecting the individual&#39;s divided attention. Normally, people can deal with two or more simple tasks simultaneously in their daily lives and are not disturbed. However, when brain function is impaired, there may be more dual-task interference when faced with simple dual tasks; that is, when performing dual tasks, the reduced divided attention may be likely to cause the performance of one or two tasks to be impaired15. It is concluded that dual-task execution is more likely to be able to detect advanced cognitive function impairment in patients with high-functioning stroke.
The Stroop paradigm is a classical experimental paradigm to study the Stroop effect (also known as the conflict effect)16, which has been widely used in attention assessment in cognitive function tests, especially in the field of attention inhibition17. The classical Stroop effect refers to the fact that it is difficult for individuals to respond quickly and accurately to non-dominant stimuli due to the interference of the dominant response. This results in a longer response time and lower response accuracy for non-dominant stimuli. The difference in reaction time or accuracy rate between dominant and non-dominant reactions is the Stroop effect18. Therefore, the Stroop requires high levels of attention19. Smaller Stroop effects represent higher attentional inhibition, while larger Stroop effects represent a decline in attentional inhibition18.
The Stroop paradigm may be more suitable for assessing cognitive dysfunction in patients with high-functioning stroke and has higher sensitivity and specificity for attention assessment than the traditional clinical assessment scale20. Therefore, this study designed a dual-task assessment based on the Stroop paradigm to identify cognitive deficits in high-functioning stroke patients. The protocol also includes clinical assessment of cognitive function, lower limb motor function, and balance function in stroke patients to ensure that patients can complete the dual-task assessment. Functional near-infrared spectroscopy (fNIRS) was used as an objective evaluation tool for brain function to detect the activation of brain function in high-functioning stroke patients under the dual task. The effectiveness and feasibility of the dual-task assessment scheme based on the Stroop paradigm were verified from the perspective of neuroimaging, which provides new aspects for clinical practice.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Balance Ball</td>
			<td>Shanghai Fanglian Industrial Co,&#160;China</td>
			<td>PVC-KXZ-EVA01-2015</td>
			<td>NA</td>
		</tr>
		<tr>
			<td>E-Prime 3.0</td>
			<td>Psychology softwares Tools</td>
			<td></td>
			<td>commercial stimulus presentation software</td>
		</tr>
		<tr>
			<td>fNIRS</td>
			<td>Hui Chuang, China</td>
			<td>NirSmart-500</td>
			<td>NA</td>
		</tr>
	</tbody>
</table>

dual-task stroop paradigm for detecting cognitive deficits in high-functioning stroke patients

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task assessment has advantages for identifying cognitive deficits in high-functioning stroke patients and has been gradually applied in clinical assessment and cognitive training. Moreover, the Stroop paradigm has higher sensitivity and specificity for attentional assessment than conventional clinical cognitive assessment scales. Therefore, this study presents the dual-task assessment based on the Stroop paradigm to identify cognitive deficits in high-functioning stroke patients. This study demonstrates a single- and dual-task evaluation based on the Stroop paradigm and confirms its feasibility through case experiments and synchronized functional near-infrared spectroscopy evaluation. The Stroop reaction time and correct rate are used as the main indicators to evaluate the cognitive level of the subjects. This study protocol aims to provide new ideas to figure out the ceiling effect in general clinical assessment failure for high-functioning stroke patients.

This study presents results from a high-functioning stroke patient, who was a 71-year-old male who suffered from ischemic stroke with left hemiplegia 2 years ago. The magnetic resonance imaging (MRI) presented bilateral chronic infarction from the basal ganglia to the radiating crown. He was able to walk and live independently in the community but was not satisfied with his cognitive recovery. However, the functional assessments were all within the normal range: FMA = 100, BBS = 56/56, TUGT = 6, MoCA = 26/30, CDR = 0.5, ...

Watch this Scientific Journal Video about Dual-Task Stroop Paradigm for Detecting Cognitive Deficits in High-Functioning Stroke Patients at JoVE.com

Dual-Task Stroop Paradigm for Detecting Cognitive Deficits in High-Functioning Stroke Patients

Clinical assessment scales are notsensitive enough to cognitive dysfunction in high-functioning stroke patients. The dual-task paradigm presents advantages and potential in the assessment and cognitive training of cognitive dysfunction. The study here proposes a dual-task Stroop paradigm to identify cognitive dysfunction in high-functioning stroke patients.

General clinical cognitive assessment scales are not sensitive enough to cognitive impairment in high-functioning stroke patients. The dual-task ...

Our study protocol could be used to identify cognitive deficit in high functioning stroke patients who are not easily detected by conventional assessment skills. This study protocol is to provide new ideas to figure out effect in general clinical assessment failure for high functioning stroke patients. This study protocol could be easily used in the clinical practice.For example, the clinician could modify the treatment strategy based on the Stroop reaction time and the correct rate. Demonstrating the procedure will be Siqi Huang, rehabilitation therapist;Siqing Wang, occupational therapist;Yajie Zhanga, physical therapist, Biyi Zhao, occupational therapist from our lab. Recruit stroke patients with stable conditions at Brunnstrom Stage 4 as confirmed by imaging examination.Ensure that the subjects participate in the test voluntarily and sign an informed consent form. Record the information of the participant, including name, gender, date of birth, education level, body mass index, medical history, and medication history. For cognitive assessment, perform MoCA on the participants by asking 11 questions addressing their attention and concentration, executive function, memory, language, visual structure skills, abstract thinking, computing, and orientation.Then perform CDR by collecting information during structured interviews with the participants and their families to assess the abilities of the participants in aspects such as memory, orientation, judgment and problem solving, work and social interaction, family life, personal hobby, and independent living. Perform Albert's Test to detect the presence of unilateral spatial neglect in patients with stroke. Ask the subject to cross out all the lines that are placed in random orientations on a piece of paper.Next, perform Fugl-Meyer Assessment on the participants to assess sensation, balance, joint range of motion, and joint pain in patients with post-stroke hemiplegia. The motor function includes items assessing movement, coordination, and the reflex actions of the shoulder, elbow, forearm, wrist, hand, hip, knee, and ankle. Also perform Berg Balance Scale on the stroke patient with a total of 14 items from easy to difficult including sitting balance, standing balance, body transfer, turning, and single leg standing.Perform the timed up and go test. Ask the subject to stand up from the chair, walk for three meters, turn their body, then return and sit in the chair. Concurrently, time the whole process from issuing the departure order to sitting in the chair.Prepare the participant by ensuring that the CZ site at the top of the test cap, which is the fourth point from the forehead to the occipital lobe, is on the midline of the full cap. Ensure that the midpoint of the connection lies between the nasal root to the lower edge of the occipital protuberance, the connection between the superior auricular fossa of both ears or the intersection point of the connection from the nasal root to the occipital protuberance. Then click the pre-acquisition button to start pre-acquisition and calibrate the test signal.Perform Stroop single task evaluation synchronized with fNIRS. Then perform Stroop dual task evaluation synchronized with fNIRS. First, ask the patient to sit in a stable chair.Run the commercial stimulus presentation software and select the congruence test trials. Make a new profile for the patient. Select the congruence test trials of the Stroop task and repeat three trials.In the resting stage, ask the patient to relax. When the experiment is in the stimulation stage, ask the patient to perform the attention related test and complete the task in six seconds. The patient should complete it 10 times in 60 seconds.Ask the patient to follow the instructions for the two test trials. Select the congruence test trials. Click the arrow button to the left when left is shown.Click the arrow button to the right when right is shown. Select the incongruence task trials. Click the arrow button to the left as soon as possible when right is shown on the left of the square.Click the arrow button to the right as soon as possible when left is shown on the right of the square. Finish the task, save the data and export the data to a self-built database. To perform the Stroop dual task evaluation, ask the patient to sit on a balance ball.Let the patient complete the Stroop experimental paradigm with the steps shown in the previous step. When the experiment is in a resting stage ask the patient to keep balance and relax on the balance ball. When the experiment is on stimulation, ask the patient to carry out the attention related test while maintaining balance on the balance ball as much as possible.This study presents cognitive assessment of a high functioning stroke patient compared to a healthy subject. In dual task congruence test trials, the reaction time of the stroke patient was higher than that of a healthy young subject and their accuracy was relatively lower. This difference was greater in the incongruence test trials.The results for brain function showed that the beta value of the regions of interest in the stroke patient was lower than that in the healthy young subject while performing dual task Stroop. Blood oxygen concentration in brain regions was shown. The beta values in the stroke patient were lower than that in the healthy young subject during dual task performance.During the dual task case, the evaluator should protect participant to avoid occurrence of accidental injuries such as falling. Our study protocol was mainly used to evaluate acuity function. The different types and difficult levels of dual tasks should be studied in the future.Dual task assessment in our study protocol could identify cognitive deficit in high functioning patients which will pave the way for the development of individualized treatment plans.

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2.6K visualizações.  Guangzhou University of Chinese Medicine, Shenzhen Traditional Chinese Medicine Hospital. Nosso protocolo de estudo poderia ser usado para identificar déficit cognitivo em pacientes com AVC de alto funcionamento que não são facilmente detectados pelas habilidades convencionais de avaliação. Este protocolo de estudo é fornecer novas ideias para descobrir o efeito na falha na avaliação clínica geral de pacientes com AVC de alto funcionamento. Este protocolo de estudo poderia ser facilmente utilizado na prática clínica.Por exemplo, o clínico poderia modificar a est...