The Effect of Internal- or External-Focused Exercise Training, Administered in Conjunction With a Cognitive Task, on Walking, Balance, and Cognitive Functions in Individuals With Multiple Sclerosis

The Effect of Internal- or External-Focused Exercise Training, Administered in Conjunction With a Cognitive Task, on Walking, Balance, and Cognitive Functions in Individuals With Multiple Sclerosis

This interventional clinical trial aims to investigate the effects of internal and external focus-based exercise training combined with cognitive dual-task training in individuals diagnosed with multiple sclerosis. The primary objective is to determine whether these exercise approaches improve gait, balance, and cognitive functions.

The main research questions are:

Does dual-task training combined with internal focus-based exercises improve gait, balance, and cognitive performance? Does dual-task training combined with external focus-based exercises lead to greater improvements compared to internal focus strategies?

Participants will be divided into two groups, and the researchers will compare the effects of internal focus-based and external focus-based dual-task exercise training on functional outcomes.

Participants will:

Perform structured exercise sessions under the supervision of a physiotherapist Engage in dual-task activities by combining motor exercises with simple cognitive tasks (e.g., backward counting, word generation) Participate in an 8-week training program, with sessions held twice a week lasting approximately 45-60 minutes Undergo assessments of gait, balance, and cognitive function before and after the intervention

This study does not involve invasive procedures or biological sample collection. The findings are expected to contribute to the development of more effective dual-task rehabilitation strategies for individuals with multiple sclerosis.

Multiple sclerosis (MS) is a chronic neurological disease characterized by motor and cognitive impairments that significantly affect functional mobility and independence. Dual-task performance, which requires the simultaneous execution of motor and cognitive tasks, is frequently impaired in individuals with MS and has been associated with decreased gait performance, balance deficits, and increased risk of falls.

In recent years, dual-task training has emerged as an effective rehabilitation approach to improve functional performance in neurological populations. In addition, attentional focus strategies, including internal focus (focusing on body movements) and external focus (focusing on movement outcomes), have been shown to influence motor learning and performance. However, the comparative effects of internal and external focus strategies when combined with dual-task training in individuals with MS remain unclear.

This study is designed as an interventional clinical trial to investigate the effects of dual-task training combined with internal and external focus-based exercise approaches on gait, balance, and cognitive functions in individuals with MS. Participants will be allocated into two groups receiving either internal focus-based or external focus-based dual-task training.

The intervention program will be conducted over an 8-week period under the supervision of a physiotherapist. Outcome measures will include assessments of gait performance, balance, and cognitive function before and after the intervention. The results of this study are expected to provide evidence for optimizing dual-task rehabilitation strategies and improving functional outcomes in individuals with MS.

Inclusion Criteria:

• Diagnosis of Multiple Sclerosis according to the revised McDonald criteria
• Aged between 20 and 60 years
• Ability to understand and follow simple instructions
• Ability to stand and walk independently or with an assistive device
• Ability to speak and understand Turkish
• Score of ≥21 on the Montreal Cognitive Assessment (MoCA)
• Willingness to participate in the study

Exclusion Criteria:

• MS relapse within the last 30 days
• Presence of any other neurological disease besides Multiple Sclerosis
• Any musculoskeletal condition that may affect walking or balance
• History of uncontrolled cardiorespiratory conditions within the last 3 months (e.g., hypertension, arrhythmia, tachycardia, or acute cardiopulmonary events)
• Severe visual or hearing impairment