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This randomized controlled trial aims to investigate the effects of an 8-week dual-task exercise training program compared to conventional functional exercise training on motor and cognitive functions in adolescents with pediatric-onset multiple sclerosis (PBMS). PBMS is a rare, chronic demyelinating disease of the central nervous system that begins in childhood or adolescence and often leads to motor impairments, balance problems, fatigue, and cognitive deficits, particularly in information processing speed, attention, memory, and executive functions. These symptoms significantly affect independence in daily activities and quality of life.
Participants aged 12-18 years with PBMS diagnosis (according to the 2017 revised McDonald criteria) and Expanded Disability Status Scale (EDSS) score below 6 will be randomly assigned to two parallel groups. Both groups will receive 16 supervised sessions (twice a week for 8 weeks, approximately 45 minutes per session). The conventional exercise group will perform structured functional exercises including aerobic stepping, progressive strengthening, and balance training. The dual-task group will perform the same motor exercises while simultaneously completing cognitive tasks (such as backward counting, color and object matching, simple mathematical operations, alphabet-based word finding, and short story telling). Cognitive task difficulty will be progressively increased weekly.
Outcomes will be assessed at baseline and immediately after the 8-week intervention. Primary outcomes include motor function (6-Minute Walk Test), functional mobility (Timed Up and Go Test), balance (Mini-BESTest), and cognitive performance (Brief International Cognitive Assessment for Multiple Sclerosis - BICAMS battery). Secondary outcomes include fatigue (PedsQL Multidimensional Fatigue Scale), health-related quality of life (PedsQL Generic Core Scales - child and parent versions), and Multiple Sclerosis Functional Composite (MSFC). We hypothesize that the dual-task exercise program will produce superior improvements in motor functions, balance, cognitive performance, fatigue, and quality of life compared to conventional exercise training.
Pediatric-onset multiple sclerosis (PBMS) is a chronic inflammatory demyelinating disorder of the central nervous system that begins in childhood or adolescence. It can cause significant long-term motor deficits, balance problems, fatigue, and cognitive impairments that negatively affect school performance, social participation, and overall quality of life (Ghezzi et al., 2017; McKay et al., 2019).
Traditional rehabilitation approaches in PBMS often address motor and cognitive domains separately, whereas most daily life activities require the simultaneous integration of motor and cognitive skills. Dual-task training, which involves performing motor and cognitive tasks concurrently, has been shown to improve the interaction between these systems, enhance neuroplasticity, and lead to better functional outcomes in adult multiple sclerosis populations (Abasıyanık & Kahraman, 2022; Ekici et al., 2025; Beste et al., 2018).
However, evidence regarding the effectiveness of dual-task training specifically in pediatric-onset multiple sclerosis remains limited. This single-center, randomized controlled trial aims to fill this gap by comparing the effectiveness of a structured dual-task exercise program versus a dose-matched conventional functional exercise program in adolescents with PBMS.
Study Design and Intervention
A total of 20 participants (10 per group) will be recruited. After baseline assessment, participants will be randomly allocated to one of two groups:
Dual-Task Exercise Group: Participants will perform aerobic, strengthening, and balance exercises while simultaneously engaging in cognitive tasks. Cognitive tasks include backward counting, color/object matching, mental arithmetic, alphabet-based word finding, and short storytelling. Task difficulty will be progressively increased over the 8 weeks.
Conventional Functional Exercise Group: Participants will receive a traditional physiotherapy program consisting of warm-up, aerobic stepping exercises, progressive strengthening (bridge, squats, lunges, etc.), balance training (tandem stance, single-leg stance), and cool-down exercises without concurrent cognitive loading.
Both interventions will last 8 weeks, with sessions held twice weekly for approximately 45 minutes each (5 min warm-up, 35 min main exercises, 5 min cool-down). All sessions will be supervised by a physiotherapist at Istanbul University-CerrahpaÅŸa Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation.
Outcome Measures
Assessments will be conducted before and after the intervention period using the following validated tools:
Motor function and walking endurance: 6-Minute Walk Test (6MWT) Functional mobility: Timed Up and Go Test (TUG) Balance: Mini-BESTest Cognitive functions: Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery Fatigue: PedsQL Multidimensional Fatigue Scale (MFS) Health-related quality of life: Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales (child and parent forms) Multiple Sclerosis Functional Composite (MSFC)
This study is expected to provide important evidence on whether incorporating dual-task training into pediatric MS rehabilitation yields greater benefits on motor, cognitive, and functional outcomes compared to conventional exercise. The findings may contribute to the development of more effective, motivating, and holistic rehabilitation strategies for children and adolescents with PBMS.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Dual-Task Exercise Training | Experimental | Participants in this group will receive an 8-week structured dual-task exercise program. The intervention consists of 16 supervised sessions (2 sessions per week, approximately 45 minutes per session). Each session includes three phases: a 5-minute warm-up, 35 minutes of main exercises, and a 5-minute cool-down. The program combines motor exercises (aerobic, strengthening, and balance training) with simultaneous cognitive tasks targeting attention, working memory, and executive functions. Motor exercises include progressive aerobic stepping patterns, strengthening exercises (bridge, squats, lunges, single-leg stance), and balance exercises (tandem stance, single-leg balance, weight shifting). Cognitive tasks performed concurrently with motor exercises include backward counting, color and object matching, simple mathematical operations, alphabet-based word finding, and short story telling. The difficulty level of both motor and cognitive components will be progressively increased weekl |
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| Conventional Functional Exercise Training | Experimental | Participants in this group will receive a dose-matched 8-week conventional functional exercise program consisting of 16 supervised sessions (2 sessions per week, approximately 45 minutes per session). Each session follows the same structure: a 5-minute warm-up, 35 minutes of main exercises, and a 5-minute cool-down. The program includes progressive aerobic exercises (multi-directional stepping, light jogging patterns), strengthening exercises (bridge, squats, lunges, hip strengthening, core stabilization), and balance training (tandem stance, single-leg stance, dynamic balance activities). Unlike the experimental group, motor exercises are performed without any concurrent cognitive tasks. The intensity and progression of exercises will be individually adjusted weekly based on participant tolerance, similar to the dual-task group, to ensure equal training dose between groups. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Dual-Task Exercise Training | Behavioral | This intervention involves the simultaneous performance of motor and cognitive tasks during structured physiotherapy sessions. The motor component includes: Warm-up (5 min): Low-intensity walking and upper extremity range of motion exercises. Aerobic exercises (20-25 min): Multi-directional stepping, forward-backward and cross stepping, side stepping, and light jogging patterns to improve cardiovascular endurance and coordination. Strengthening and balance exercises (progressive): Bridge exercise, squats, lunges, single-leg stance, tandem stance, core stabilization, and hip strengthening exercises. Difficulty is increased gradually by adding repetitions, sets, or resistance (e.g., free weights) over the 8 weeks. Cognitive tasks (performed simultaneously with motor exercises): Backward counting by 3s or 7s, color and object matching, simple arithmetic operations, alphabet-based word generation, and short story telling. Cognitive task complexity is progressively increased each week. Coo |
| Measure | Description | Time Frame |
|---|---|---|
| Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery | Scores obtained from the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery, which includes three tests: Symbol Digit Modalities Test (SDMT) for information processing speed and attention, California Verbal Learning Test-II (CVLT-II) for verbal learning and memory, and Brief Visuospatial Memory Test-Revised (BVMT-R) for visuospatial learning and memory. Higher scores indicate better cognitive function. | Baseline and at 8 weeks |
| 6-Minute Walk Test | Distance covered during the 6-Minute Walk Test (6MWT). This test measures functional exercise capacity and walking endurance. Higher distance indicates better motor performance. | Baseline and at 8 weeks |
| Measure | Description | Time Frame |
|---|---|---|
| Mini-BESTest | Total score and subsection scores of the Mini-BESTest (Mini Balance Evaluation Systems Test). This 14-item scale assesses anticipatory postural control, reactive postural control, sensory orientation, and dynamic gait. Higher scores indicate better balance control (maximum score: 28). | Baseline and at 8 weeks |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Yonca Zenginler Yazgan | Contact | +905326006294 | yoncazenginler@gmail.com | |
| Ayten Alihuseynli | Contact | +905057374556 | alihuseynliayten@gmail.com |
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Istanbul University-Cerrahpaşa, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Istanbul, Turkey | Recruiting | Istanbul | 34000 | Turkey (Türkiye) |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 31049039 | Result | Sikes EM, Richardson EV, Motl RW. A Qualitative Study of Exercise and Physical Activity in Adolescents with Pediatric-Onset Multiple Sclerosis. Int J MS Care. 2019 Mar-Apr;21(2):81-91. doi: 10.7224/1537-2073.2018-033. | |
| 20060544 | Result | Weikert M, Motl RW, Suh Y, McAuley E, Wynn D. Accelerometry in persons with multiple sclerosis: measurement of physical activity or walking mobility? J Neurol Sci. 2010 Mar 15;290(1-2):6-11. doi: 10.1016/j.jns.2009.12.021. Epub 2010 Jan 8. |
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| Conventional Functional Exercise Training | Behavioral | This control intervention consists of a structured, progressive conventional physiotherapy program matched in duration, frequency, and total exercise dose to the dual-task group. The program includes: Warm-up (5 min): Low-intensity walking and upper extremity mobility exercises. Aerobic exercises (20-25 min): Progressive stepping exercises in multiple directions, coordination movements, and light aerobic activities. Strengthening and balance exercises: Progressive resistance training targeting lower extremity and core muscles (bridge, squats, lunges, single-leg support, tandem stance) and dynamic balance activities. Exercise intensity and volume are increased weekly based on individual capacity. Cool-down (5 min): Stretching and breathing exercises. No concurrent cognitive tasks are added to the motor exercises in this group. This arm serves as an active comparator to evaluate the additional benefit of the dual-task component. |
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| Timed Up and Go Test (TUG) |
Time taken to complete the Timed Up and Go Test (TUG). Participants rise from a chair, walk 3 meters, turn, walk back, and sit down. Shorter time indicates better functional mobility and dynamic balance. |
| Baseline and at 8 weeks |
| PedsQL Multidimensional Fatigue Scale | Scores from the PedsQL Multidimensional Fatigue Scale (PedsQL MFS). This 18-item scale evaluates general fatigue, sleep/rest fatigue, and cognitive fatigue from both child self-report and parent proxy-report perspectives. Higher scores indicate lower fatigue levels (0-100 scale). | Baseline and at 8 weeks |
| Pediatric Quality of Life Inventory (PedsQL) | Scores from the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scales (4.0). This scale includes physical, emotional, social, and school functioning domains, completed by both the child/adolescent and one parent. Higher scores reflect better health-related quality of life (0-100 scale). | Baseline and at 8 weeks |
| Multiple Sclerosis Functional Composite (MSFC) | Overall score of the Multiple Sclerosis Functional Composite (MSFC), which combines three components: Timed 25-Foot Walk Test (T25FW) for lower extremity function, Nine-Hole Peg Test (NHPT) for upper extremity function, and Paced Auditory Serial Addition Test (PASAT-3") for cognitive function. Z-scores are calculated and averaged. Higher composite score indicates better overall neurological function. | Baseline and at 8 weeks |
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| 27717498 | Result | Grover SA, Sawicki CP, Kinnett-Hopkins D, Finlayson M, Schneiderman JE, Banwell B, Till C, Motl RW, Yeh EA. Physical Activity and Its Correlates in Youth with Multiple Sclerosis. J Pediatr. 2016 Dec;179:197-203.e2. doi: 10.1016/j.jpeds.2016.08.104. Epub 2016 Oct 4. |
| 26944709 | Result | Sebastiao E, Sandroff BM, Learmonth YC, Motl RW. Validity of the Timed Up and Go Test as a Measure of Functional Mobility in Persons With Multiple Sclerosis. Arch Phys Med Rehabil. 2016 Jul;97(7):1072-7. doi: 10.1016/j.apmr.2015.12.031. Epub 2016 Mar 2. |
| 35091209 | Result | Wollesen B, Janssen TI, Muller H, Voelcker-Rehage C. Effects of cognitive-motor dual task training on cognitive and physical performance in healthy children and adolescents: A scoping review. Acta Psychol (Amst). 2022 Apr;224:103498. doi: 10.1016/j.actpsy.2022.103498. Epub 2022 Jan 25. |
| 29445335 | Result | Beste C, Muckschel M, Paucke M, Ziemssen T. Dual-Tasking in Multiple Sclerosis - Implications for a Cognitive Screening Instrument. Front Hum Neurosci. 2018 Jan 31;12:24. doi: 10.3389/fnhum.2018.00024. eCollection 2018. |
| 40737966 | Result | Ekici PE, Ozkeskin PM, Yuceyar MAN. Effects of dual-task training on balance, gait, dual-task performance, cognitive function, fatigue in individuals with multiple sclerosis: A randomized controlled trial: Dual-Task Training in MS. Mult Scler Relat Disord. 2025 Oct;102:106645. doi: 10.1016/j.msard.2025.106645. Epub 2025 Jul 26. |
| 12091180 | Result | ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: guidelines for the six-minute walk test. Am J Respir Crit Care Med. 2002 Jul 1;166(1):111-7. doi: 10.1164/ajrccm.166.1.at1102. No abstract available. |
| 10467383 | Result | Fischer JS, Rudick RA, Cutter GR, Reingold SC. The Multiple Sclerosis Functional Composite Measure (MSFC): an integrated approach to MS clinical outcome assessment. National MS Society Clinical Outcomes Assessment Task Force. Mult Scler. 1999 Aug;5(4):244-50. doi: 10.1177/135245859900500409. |
| 11468499 | Result | Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care. 2001 Aug;39(8):800-12. doi: 10.1097/00005650-200108000-00006. |
| 29207954 | Result | Ozakbas S, Yigit P, Cinar BP, Limoncu H, Kahraman T, Kosehasanogullari G. The Turkish validation of the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) battery. BMC Neurol. 2017 Dec 6;17(1):208. doi: 10.1186/s12883-017-0993-0. |
| 35430546 | Result | Abasiyanik Z, Kahraman T. Effect of dual-task training on cognitive functions in persons with multiple sclerosis: A systematic review and meta-analysis. Mult Scler Relat Disord. 2022 Jun;62:103801. doi: 10.1016/j.msard.2022.103801. Epub 2022 Apr 10. |
| 31206130 | Result | McKay KA, Manouchehrinia A, Berrigan L, Fisk JD, Olsson T, Hillert J. Long-term Cognitive Outcomes in Patients With Pediatric-Onset vs Adult-Onset Multiple Sclerosis. JAMA Neurol. 2019 Sep 1;76(9):1028-1034. doi: 10.1001/jamaneurol.2019.1546. |