SMARTfit Dual Task Cost Baseline and Progress Tests

Science and common sense tell us that almost all human performance at any age or ability starts with the brain. The ability of the brain (cognitive) and body (physical or motor) to work simultaneously together, also known as dual tasking, is essential. If cognitive or physical capabilities are diminished, we see a loss in performance, or “cost” when doing both. Science also tells us that we can measure and improve performance with dual-task testing and training, especially when they include a focus on executive function.

Kick Start a New Program With A Dual Task Cost Evaluation

SMARTfit’s dual task cost test is a great way to start a new program as it provides a baseline assessment at the start and then tracks results during the program sessions to show the effectiveness of the program.

There are three steps to the test.

  1. Physical Test: assesses strength, balance and or gait.
  2. Cognitive Test: Broken down into levels of complexity
  3. Dual Task Cost Test: The two tasks of physical and cognitive are done together.

The test results will then compare the change in performance when doing the single physical and cognitive tasks with the dual task. The “Cost” of doing both physical and cognitive tasks together can indicate a person’s risk of cognitive and/or motor decline such as risk of fall, decline in attention to task during an routine activity daily living, etc

This score indicates a person’s risk of cognitive and/or motor decline. By tracking dual task cost before, during at of at least 6 weeks, while engaging in dual task gamified programs it is easy to Measure progress. The aim in training is to reduce the dual task cost.

How is SMARTfit's Dual Task Cost Test Different?

SMARTfit’s Dual Task Cost Tests Take 5 Minutes each and Provide Instant Reporting

The challenge has been “How to measure Dual Task Cost” with consistency and data tracking. SMARTfit is the solution!

This video shows an example of how a test is conducted as well as how to use the instant report generated to interpret cognitive and motor weaknesses. It also provides a guide on which SMARTfit pre-designed programs would best help to address these weaknesses.

Periodic retesting will provide detailed graphs on the progress being made.

SMARTfit delivers the world’s first comprehensive baseline test of cognitive capabilities while the person is moving, followed by a 12-week program to improve identified weaknesses.

Designed initially for older adults, SMARTfit training improves ADLs (activities of daily living), mitigates fall risk, and can slow or prevent MCI and Parkinson’s. 

Disclaimer:  SMARTfit’s 14 dual task cost tests are designed to provide a baseline and progress reports to assist in validation of treatment.  We recommend using the test to track progress against the initial baseline test.  Since every person is unique in their combination of cognitive and motor capabilities, there is no intention of attempting to capture normatives.

From Our Developers of the SMARTfit Dual Task Cost Tests, Dr. Rob Winningham and Dr Mike Studer

SMARTfit’s Dual Task Cost Measures

Understanding the Science and the Practical Applications for Your Business

“Based on extensive scientific research, SMARTfit dual tasking can improve executive functioning better than physical exercise alone or cognitive exercise alone through dual tasking, especially for vulnerable populations. [1, 2, 3, 4, 5, 6, 7, 8] The research supports that, and, if we can improve executive functioning then that should generalize to things that have never been trained including activities of daily living that can maximize independence and quality of life. [9, 10, 11] This includes the ability to create a new memory, ability to pay attention, ability to inhibit behavior, problem solving and reasoning.”

Dr. Rob Winningham
Ph.D. Neuroscience, Published Author, Western Oregon University.

In 2020, SMARTfit engaged two of the most widely recognized authorities in dual task cost, to create what we have today. Using SMARTfit technology, Dr. Robert Winningham, geriatric neuropsychologist, and Dr. Mike Studer, award-winning physical therapist, created an intuitive test battery using clinically validated and widely used physical assessments plus the most current scientific evidence on dual task testing and training. 

What is Dual Task Cost?

Dual Task Cost (DTC) is an expression of how much a distraction or a secondary task influences an individual’s performance. SMARTfit is able to calculate an individual’s motor, cognitive and dual task performance (or dual task cost), making it effortless for the clinician or trainer to document and communicate the objective measures, expressed as a percentage of performance change between a concentrated (single task) effort and a distracted (dual task) effort. 

Research has shown that this dual task measure can predict who is likely to develop dementia12, have mild cognitive impairment13, have physical brain changes associated with cognitive impairment12, walk safely14 or engage in a cognitive task while walking4 after a mild brain injury.15  Dual task cost can also predict fall risk for some at-risk populations.16,17 DTC can even predict sport performance.18 Researchers have reported that dual task cost is a significantly more sensitive measure than typical single task assessments.19,20 

Why do we need to measure Dual Task Cost?

  • Reimbursement – Objective measures help us to justify an individual’s care, to engage referral sources and to fulfill state regulations. 
  • Accountability – Patients benefit from an independent third-party arbitrator and not simply the opinion of a therapist that “you are doing better”.  SMARTfit’s technology creates an unbiased report that is intuitive for patients and caregivers to determine if help is needed and if progress is being made.
  • Treatment efficacy – Dual Task Cost baseline tests and retests track specific physical and cognitive metrics that affect human performance, measuring whether treatments are effective, and if continued work is needed, alone or with other individuals. SMARTfit’s technology automatically measures those results and recommends programs to improve.
  • Most important – With SMARTfit, the patient is engaged through Dual Task Gamification. Patients who know their scores and see their improvement typically participate with more repetitions (“let me try that again”), or more intensity (“I need to beat this score”), ultimately leading to rewards both psychologically (increasing confidence and motivation) and chemically (producing dopamine).

Who needs Dual Task measurement, and treatment?

  • SMARTfit can help people who are interested in many aspects of life, from learning new skills to avoiding the negative effects including falls of being distracted during basic activities of daily living or at work to studying in different environments.
  • People who are interested in improving their existing skills include very high-level professional athletes, school children, and those preparing themselves to work in distracting environments.
  • People who are interested in relearning include those who have lost or reduced skills due to injury or illness.
  • People who need to preserve skills include those who are at risk due to degenerative conditions or the process of aging.

When should we measure people or patients…and when should we re-measure?

In each of the above categories, we see people who would benefit from a baseline knowledge of their physical, cognitive, and dual-task abilities and what they can do to improve and/or maintain them. When we first engage people or patients (preventative wellness vs. rehabilitative considerations), a baseline of their dual task performance should be captured. 

When to re-measure is more complicated. Retesting must be conducted thoughtfully with consideration for personality, condition, and frequency of programming as which variables can and should be considered must be identified prior to retesting. 

How was SMARTfit’s Dual Task Cost battery developed and is it valid?

Drs. Winningham and Studer used a very clear approach in developing the Dual Task Cost battery. They started by using validated and widely used measures, followed by the use of the science of dual tasking to build both the testing and training tools.

The physical tasks were based on the United States Centers for Disease Control screening exam known as the STEADI.21 This included the Four Stage Balance Test (FSBT)22; the Timed Up and Go (TUG)23,24; and the 30 Second Sit to Stand Test (30SSTS).25 The cognitive tests used have also been subjected to validity testing and widespread clinical usage. The standardization and previous validity testing of the physical and cognitive measures used by SMARTfit affords optimal reliability. Researchers have also confirmed the reliability and validity of combining physical and cognitive tests in a dual task context.26

The cognitive tasks required options for levels of difficulty, affording participants the opportunity to participate even if they started with a baseline level of cognitive impairment. Knowing that educational levels and novelty can negatively bias the tests, making them less reliable and less valid. So, the developers chose a baseline knowledge of the English alphabet. 

In considering trivia, full word recognition, color blindness, and stigmatization and pessimistic perspectives about numbers and calculations, it was evident to all of us that the alphabet, albeit not worldwide and perfect, would be the superior choice. 

In addition to the dual task testing tools, SMARTfit also offers numerous dual task training interventions that differ from the testing tools. Many of these tools have also been subjected to validity testing.27, 28, 29, 30, 31

As users of the SMARTfit Dual Task Cost folders continue to record subject, patient, customer experiences and the user database grows, normative values can be ascribed. 

Now that we are a little over two years into the release in July 2021 of the Dual Task Cost folders, we can begin to consider a validation study of these tests.  Today, SF’s Dual Task Cost folders already deliver a degree of reference validity given these facts:

  1. The physical tasks are based on gold standards that have been validated. 
  2. The methodology for the DT Cost equation is established and validated. 
  3. The cognitive distractor is based on the alphabet, yielding results that do not have inherent bias for familiarity or educational level. 


  1. Wang R-Y, Huang Y-C, Zhou J-H, Cheng S-J, Yang Y-R. Effects of exergame-based dual-task training on executive function and dual-task performance in community-dwelling older people: A randomized-controlled trial. Games for Health. 2021;10(5):347-354. doi:10.1089/g4h.2021.0057
  2. Liu C-L, Cheng F-Y, Wei M-J, Liao Y-Y. Effects of exergaming-based Tai Chi on cognitive function and dual-task gait performance in older adults with mild cognitive impairment: A randomized control trial. Frontiers in Aging Neuroscience. 2022;14. doi:10.3389/fnagi.2022.76105
  3. Elsarafy LS. The effects of an online movement and cognitive dual task training program for community-based adults and older adults on executive function: A pilot study. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2023;84(2-B). Accessed September 22, 2023.,cookie,url,uid&db=psyh&AN=2023-01883-081&site=ehost-live
  4. Park J-H. Is Dual-Task Training Clinically Beneficial to Improve Balance and Executive Function in Community-Dwelling Older Adults with a History of Falls? International journal of environmental research and public health. 2022;19(16). doi:10.3390/ijerph191610198
  5. Park M-O, Lee S-H. Effect of a dual-task program with different cognitive tasks applied to stroke patients: A pilot randomized controlled trial. NeuroRehabilitation. 2019;44(2):239-249. doi:10.3233/NRE-182563
  6. Abasıyanık, Z., & Kahraman, T. (2022). Effect of dual-task training on cognitive functions in persons with multiple sclerosis: A systematic review and meta-analysis. Multiple Sclerosis and Related Disorders, 62, 103801.
  7. Zhang W, Liu H, Zhang T. Immediate and short-term effects of single-task and motor-cognitive dual-task on executive function. PloS one. 2023;18(8):e0290171. doi:10.1371/journal.pone.0290171
  8. Ali N, Tian H, Thabane L, et al. The Effects of Dual-Task Training on Cognitive and Physical Functions in Older Adults with Cognitive Impairment; A Systematic Review and Meta-Analysis. The journal of prevention of Alzheimer’s disease. 2022;9(2):359-370. doi:10.14283/jpad.2022.16
  9. Razani J, Casas R, Wong JT, Lu P, Alessi C, Josephson K. Relationship between executive functioning and activities of daily living in patients with relatively mild dementia. Applied Neuropsychology. 2007;14(3):208-214. doi:10.1080/09084280701509125
  10. Zhu L, Li L, Wang L, Jin X, Zhang H. Physical activity for executive function and activities of daily living in ad patients: A systematic review and meta-analysis. Frontiers in Psychology. 2020;11. doi:10.3389/fpsyg.2020.560461
  11. Kornblith E, Abrams G, Chen AJ-W, Burciaga J, D’Esposito M, Novakovic-Agopian T. Impact of baseline neurocognitive functioning on outcomes following rehabilitation of executive function training for veterans with history of traumatic brain injury. Applied neuropsychology Adult. 2020;27(2):108-120. doi:10.1080/23279095.2018.1490738
  12. Sakurai, R., Bartha, R., & Montero-Odasso, M. (2019). Entorhinal cortex volume is associated with dual-task gait cost among older adults with MCI: Results from the gait and brain study. The Journals of Gerontology: Series A: Biological Sciences and Medical Sciences, 74(5), 698–704.
  13. Bishnoi, A., & Hernandez, M. E. (2021). Dual task walking costs in older adults with mild cognitive impairment: A systematic review and meta-analysis. Aging & Mental Health, 25(9), 1618–1629.
  14. Howell, D. R., Brilliant, A., Berkstresser, B., Wang, F., Fraser, J., & Meehan, W. P. (2017). The association between dual-task gait after concussion and prolonged symptom duration. Journal of Neurotrauma, 34(23), 3288–3294.
  15. Bryk KN, Passalugo S, Chou L-S, et al. Dual task cost in adults with persistent concussion symptoms. Gait & posture. 2023;101:120-123. doi:10.1016/j.gaitpost.2023.02.008
  16. Etemadi Y. Dual task cost of cognition is related to fall risk in patients with multiple sclerosis: A prospective study. Clinical Rehabilitation. 2017;31(2):278-284. doi:10.1177/0269215516637201
  17. Heinzel S, Maechtel M, Hasmann SE, et al. Motor dual-tasking deficits predict falls in Parkinson’s disease: A prospective study. Parkinsonism & Related Disorders. 2016;26:73-77. doi:10.1016/j.parkreldis.2016.03.007
  18. Schaefer S, Amico G. Table tennis expertise influences dual-task costs in timed and self-initiated tasks. Acta Psychologica. 2022;223. doi:10.1016/j.actpsy.2022.103501
  19. Büttner, F., Howell, D. R., Ardern, C. L., Doherty, C., Blake, C., Ryan, J., Catena, R., Chou, L.-S., Fino, P., Rochefort, C., Sveistrup, H., Parker, T., & Delahunt, E. (2020). Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data. British Journal of Sports Medicine54(2), 94–101.
  20. Pinto, S. M., Newman, M. A., Runyon, M. S., Gibbs, M., Grafton, L. M., & Hirsch, M. A. (2022). Mild Traumatic Brain Injury Is Associated With Increased Dual-Task Cost During Ambulation: A Preliminary Study. American Journal of Physical Medicine & Rehabilitation, 101(4), 367–371.
  21. Stevens JA, Phelan EA. Development of STEADI: A fall prevention resource for health care providers. Health Promotion Practice. 2013;14(5):706-714. doi:10.1177/1524839912463576
  22. Moore M, Barker K. The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev. 2017 Sep 11;6(1):187. doi: 10.1186/s13643-017-0577-5. PMID: 28893312; PMCID: PMC5594590
  23. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991 Feb;39(2):142-8. doi: 10.1111/j.1532-5415.1991.tb01616.x. PMID: 1991946.
  24. Dozzi Brucki SM. Timed Up and Go test: A simple test gives important information in elderly. Arquivos de Neuro-Psiquiatria. 2015;73(3):185-186. doi:10.1590/0004-282X20140243
  25. Le Berre M, Apap D, Babcock J, Bray S, Gareau E, Chassé K, et al. The psychometric properties of a modified sit-to-stand test with use of the upper extremities in institutionalized older adults. Percept Mot Skills. 2016;123: 138–152. doi: 10.1177/0031512516653388
  26. McCulloch KL, Mercer V, Giuliani C, Marshall S. Development of a clinical measure of dual-task performance in walking: Reliability and preliminary validity of the Walking and Remembering Test. Journal of Geriatric Physical Therapy. 2009;32(1):2-9. doi:10.1519/00139143-200932010-00002 
  27. Schroeder RW, Twumasi-Ankrah P, Baade LE, Marshall PS. Reliable Digit Span: A Systematic Review and Cross-Validation Study. Assessment. 2012;19(1):21-30. doi:10.1177/1073191111428764
  1. Periáñez JA, Lubrini G, García-Gutiérrez A, Ríos-Lago M. Construct validity of the Stroop color-word test: Influence of speed of visual search, verbal fluency, working memory, cognitive flexibility, and conflict monitoring. Archives of Clinical Neuropsychology. 2021;36(1):99-111. doi:10.1093/arclin/acaa034
  2. Sanders LMJ, Hortobágyi T, Balasingham M, Van der Zee EA, van Heuvelen MJG. Psychometric Properties of a Flanker Task in a Sample of Patients with Dementia: A Pilot Study. Dementia and geriatric cognitive disorders extra. 2018;8(3):382-392. doi:10.1159/000493750
  3. Karzmark P. Validity of the Serial Seven procedure. International Journal of Geriatric Psychiatry. 2000;15(8):677-679. doi:10.1002/1099-1166(200008)15:8<677::AID-GPS177>3.0.CO;2-4
  4. Bristow, T., Jih, C.-S., Slabich, A., & Gunn, J. (2016). Standardization and adult norms for the sequential subtracting tasks of serial 3’s and 7’s. Applied Neuropsychology: Adult, 23(5), 372–378.
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