THERAPY Magazin
Motor-cognitive training in everyday therapy
Discover how motor-cognitive training with interactive devices enhances fall prevention in physiotherapy. Learn how playful technology supports safe, effective therapy – easy to apply in everyday settings.
Miriam Keifert
Product Manager Clinical & Scientific, THERA-Trainer
Fall prevention through the use of innovative therapy devices
A precise interaction between motor, sensory and cognitive skills is necessary for everyday activities and should be taken into account for targeted fall prevention. Effects can be achieved in particular through integrated, interactive training. Through the use of innovative therapy devices, this can be implemented in everyday practice in an effective and evidence-based manner.
Fall prevention is an important aspect of physiotherapy, partly due to the ageing population and the large number of falls with sometimes serious consequences, high healthcare costs and scarce resources. The importance of fall prevention is increasingly being recognised and focuses, for example, on environmental conditions, behaviour or individual training programmes. According to the “World guidelines for falls prevention and management for older adults”, training programmes should take everyday life into account and therefore include functional exercises (e.g. stepping) and dual-task exercises (1). Balance and strength training should also be incorporated as part of an individual, challenging and progressive exercise programme (1).
Fall prevention is an important aspect of physiotherapy, partly due to the ageing population and the large number of falls with sometimes serious consequences, high healthcare costs and scarce resources. The importance of fall prevention is increasingly being recognised and focuses, for example, on environmental conditions, behaviour or individual training programmes. According to the “World guidelines for falls prevention and management for older adults”, training programmes should take everyday life into account and therefore include functional exercises (e.g. stepping) and dual-task exercises (1). Balance and strength training should also be incorporated as part of an individual, challenging and progressive exercise programme (1).
The combination of movement and thinking tasks proves to be far superior to purely physical training.
Motor-cognitive interaction
On a physical level, the main causes of an increased risk of falling are loss of muscle mass (sarcopenia) and loss of muscle power (dynapenia). Interestingly, dynapenia progresses faster than sarcopenia. This illustrates that one of the most important fall risk factors, muscular weakness, is due to deficits not only of the motor system but also of the nervous system [2]. This suggests that the focus of training therapy should not only be on motor functions, but that the cognitive component should also be taken into account. Precise interaction between motor skills, sensory systems and the central nervous system is necessary for all activities of everyday life. Mirelman et al. (3) found in their prospective study of people living in retirement homes that the risk of future falls could be predicted by performance in executive functions and attention tests. They therefore recommend training executive functions to reduce the risk of falling (3). Training the interaction between the body (motor and sensory system) and the brain is central here (4). In dual-task paradigms in particular, it becomes clear that walking also requires cognitive resources. If a person is asked to perform a cognitive task such as arithmetic in addition to walking, the gait pattern changes. The additional task requires resources that are no longer available to control walking (5).
On a physical level, the main causes of an increased risk of falling are loss of muscle mass (sarcopenia) and loss of muscle power (dynapenia). Interestingly, dynapenia progresses faster than sarcopenia. This illustrates that one of the most important fall risk factors, muscular weakness, is due to deficits not only of the motor system but also of the nervous system [2]. This suggests that the focus of training therapy should not only be on motor functions, but that the cognitive component should also be taken into account. Precise interaction between motor skills, sensory systems and the central nervous system is necessary for all activities of everyday life. Mirelman et al. (3) found in their prospective study of people living in retirement homes that the risk of future falls could be predicted by performance in executive functions and attention tests. They therefore recommend training executive functions to reduce the risk of falling (3). Training the interaction between the body (motor and sensory system) and the brain is central here (4). In dual-task paradigms in particular, it becomes clear that walking also requires cognitive resources. If a person is asked to perform a cognitive task such as arithmetic in addition to walking, the gait pattern changes. The additional task requires resources that are no longer available to control walking (5).
Motor-cognitive training: many possibilities, but what works well?
Motor-cognitive training can be carried out sequentially or simultaneously. An example of sequential training is running on a treadmill followed by cognitive training, as is still frequently practised today. Simultaneous training can involve unrelated tasks, for example running and solving cognitive tasks at the same time. Interactive training involving related tasks, such as dancing or exergames, should lead to better training effects and more closely resembles everyday situations, since the thinking task cannot usually be separated from the movement task. The advantages are that tasks are not prioritised. Due to the similarity to everyday tasks, the trainees experience a greater perceived sense of purpose, which is also reflected in their adherence to training. In addition, exergames are usually more time-saving and are perceived as motivating due to their playful character (4).
Motor-cognitive training can be carried out sequentially or simultaneously. An example of sequential training is running on a treadmill followed by cognitive training, as is still frequently practised today. Simultaneous training can involve unrelated tasks, for example running and solving cognitive tasks at the same time. Interactive training involving related tasks, such as dancing or exergames, should lead to better training effects and more closely resembles everyday situations, since the thinking task cannot usually be separated from the movement task. The advantages are that tasks are not prioritised. Due to the similarity to everyday tasks, the trainees experience a greater perceived sense of purpose, which is also reflected in their adherence to training. In addition, exergames are usually more time-saving and are perceived as motivating due to their playful character (4).
Motor-cognitive training is used in many areas, including neurology, orthopaedics, geriatrics and even paediatrics.
Improving step reaction playfully
One example of an innovative approach to motor-cognitive training is the THERA-Trainer senso, which was developed by the Swiss company Dividat as Dividat senso and has been used in numerous studies. The device uses pressure sensors in the floor plates to detect the trainee’s step movements and weight shifts. At the same time, a screen displays the games for training specific cognitive functions, which can be customised and controlled via the reactions of the floor plates (see Figure 1). For example, therapeutic staff can use a tablet to create training plans with different focal points for individual patients or view their training history. The senso is not only a training device, but also a test device that can be used to carry out assessments (see Figure 2). To ensure the right training stimulus at all times, a progression algorithm adjusts the difficulty in real time. Preventing under- and overexertion, as well as rewarding learning achievements, can be seen as essential elements in this context for maintaining motivation and optimising training success.
MindMotion® GO from Mindmaze also offers a very motivating approach. Using a monitor, the patient can interactively train their motor and cognitive skills in an immersive virtual environment based on games. The movements of the entire body are recorded by a camera, enabling training of the upper and lower extremities. For long-term training, the MindMotion® home therapy programme can be used in the home environment. It can be remotely monitored and adjusted by therapy staff, enabling a step towards telerehabilitation.
Neuroscience Research Australia developed the smart±step training game system (see Figure 3) to enable users to train intuitively, safely and independently at home. This approach uses a wireless step mat and customised versions of popular video games displayed on a monitor, such as your own TV, to improve balance and cognitive function. In one study, the participants trained for 120 minutes a week over 12 months. The
group with the smart±step training was able to reduce the number of falls by 26 per cent compared to the control group, which carried out cognitive training in a seated position (6).
One example of an innovative approach to motor-cognitive training is the THERA-Trainer senso, which was developed by the Swiss company Dividat as Dividat senso and has been used in numerous studies. The device uses pressure sensors in the floor plates to detect the trainee’s step movements and weight shifts. At the same time, a screen displays the games for training specific cognitive functions, which can be customised and controlled via the reactions of the floor plates (see Figure 1). For example, therapeutic staff can use a tablet to create training plans with different focal points for individual patients or view their training history. The senso is not only a training device, but also a test device that can be used to carry out assessments (see Figure 2). To ensure the right training stimulus at all times, a progression algorithm adjusts the difficulty in real time. Preventing under- and overexertion, as well as rewarding learning achievements, can be seen as essential elements in this context for maintaining motivation and optimising training success.
MindMotion® GO from Mindmaze also offers a very motivating approach. Using a monitor, the patient can interactively train their motor and cognitive skills in an immersive virtual environment based on games. The movements of the entire body are recorded by a camera, enabling training of the upper and lower extremities. For long-term training, the MindMotion® home therapy programme can be used in the home environment. It can be remotely monitored and adjusted by therapy staff, enabling a step towards telerehabilitation.
Neuroscience Research Australia developed the smart±step training game system (see Figure 3) to enable users to train intuitively, safely and independently at home. This approach uses a wireless step mat and customised versions of popular video games displayed on a monitor, such as your own TV, to improve balance and cognitive function. In one study, the participants trained for 120 minutes a week over 12 months. The
group with the smart±step training was able to reduce the number of falls by 26 per cent compared to the control group, which carried out cognitive training in a seated position (6).
Therapeutic benefits – not only effective for fall prevention
The combination of movement and thinking tasks proves to be far superior to purely physical training. Synergistic effects are present, as physical activity appears to cause neuroplastic effects in the brain, such as the development of new nerve cells (4). In particular, the cognitive challenge might be critical to maintaining these effects (e.g. integration of the new cells into an existing network) (4). Motor-cognitive training can improve cognitive performance, such as concentration and cognitive flexibility. Physical performance can also benefit from this type of training, which may result in improved balance or faster reaction and walking speed, among other things. These parameters are in turn associated with a reduced risk of falling (7-10).
Motor-cognitive training is used in many areas, including neurology, orthopaedics, geriatrics and even paediatrics. The results were promising: people with severe cognitive impairments showed an improvement in their general cognitive status and mental well-being as a result of motor-cognitive training, while the control group deteriorated (8).
The combination of movement and thinking tasks proves to be far superior to purely physical training. Synergistic effects are present, as physical activity appears to cause neuroplastic effects in the brain, such as the development of new nerve cells (4). In particular, the cognitive challenge might be critical to maintaining these effects (e.g. integration of the new cells into an existing network) (4). Motor-cognitive training can improve cognitive performance, such as concentration and cognitive flexibility. Physical performance can also benefit from this type of training, which may result in improved balance or faster reaction and walking speed, among other things. These parameters are in turn associated with a reduced risk of falling (7-10).
Motor-cognitive training is used in many areas, including neurology, orthopaedics, geriatrics and even paediatrics. The results were promising: people with severe cognitive impairments showed an improvement in their general cognitive status and mental well-being as a result of motor-cognitive training, while the control group deteriorated (8).
The devices can be used by most people and are very popular with therapeutic staff and patients.
Motor-cognitive training in everyday therapy
The use of such innovative devices in everyday therapy is very versatile and differs depending on the setting and target group. However, a key common feature is that the appliances are almost never left unused. The reason for this is that the devices can be used by most people and are very popular with therapeutic staff and patients.
Many report that they enjoy the training because of the playful component. In addition, the overview of the training progress after each therapy game motivates them as they endeavour to be even better next time.
The motor-cognitive training can be integrated into an efficient group training programme, but self-therapy is also possible if the person does not require direct supervision. The basis for this is the very intuitive operation via the floor plates alone. The therapy staff can assign therapy plans to the exercisers, who log in to the device, for example using a chip, and the training progress can be monitored at all times. As well as being used as training equipment, these devices can also be used for assessments to record step reaction time, for example. Ideally, an assessment is carried out before the intervention so that the therapy can be planned accordingly. In addition, further assessments should take place halfway through the stay and at the end to review progress. The results of the assessments can be clearly visualised and also taken into account for further care in the outpatient setting.
The use of such innovative devices in everyday therapy is very versatile and differs depending on the setting and target group. However, a key common feature is that the appliances are almost never left unused. The reason for this is that the devices can be used by most people and are very popular with therapeutic staff and patients.
Many report that they enjoy the training because of the playful component. In addition, the overview of the training progress after each therapy game motivates them as they endeavour to be even better next time.
The motor-cognitive training can be integrated into an efficient group training programme, but self-therapy is also possible if the person does not require direct supervision. The basis for this is the very intuitive operation via the floor plates alone. The therapy staff can assign therapy plans to the exercisers, who log in to the device, for example using a chip, and the training progress can be monitored at all times. As well as being used as training equipment, these devices can also be used for assessments to record step reaction time, for example. Ideally, an assessment is carried out before the intervention so that the therapy can be planned accordingly. In addition, further assessments should take place halfway through the stay and at the end to review progress. The results of the assessments can be clearly visualised and also taken into account for further care in the outpatient setting.
Outlook: step reaction training in everyday PT
The aim of step reaction training is to react quickly and effectively to external stimuli, for example to take steps in a certain direction in response to visual or auditory signals. Unpredictable situations, such as tripping, require a quick reaction time in order to maintain stability and gait safety. According to recent findings, the assessment of step reaction time and stepping training based on this has proven to be an effective approach to fall prevention (11). Approaches for reactive and involuntary training, such as by means of perturbation training or volitional motor-cognitive training, for example via senso, are currently being investigated.
Portable mats with integrated pressure sensors are also used, which are connected to a tablet, a screen or the TV at home and provide a playful training programme. This portable approach of “stepping training” has proven to be very practicable and effective in preventing falls (6).
Thanks to innovations such as these, the recording of step reaction time and the motor-cognitive training based on it can be used in prevention and the entire care process. It is not only available in clinics and specialised outpatient facilities. When implemented in everyday care, including as a test and training device for home visits, step reaction training becomes an interesting prospect for physiotherapy and for the healthcare of older people in general.
The aim of step reaction training is to react quickly and effectively to external stimuli, for example to take steps in a certain direction in response to visual or auditory signals. Unpredictable situations, such as tripping, require a quick reaction time in order to maintain stability and gait safety. According to recent findings, the assessment of step reaction time and stepping training based on this has proven to be an effective approach to fall prevention (11). Approaches for reactive and involuntary training, such as by means of perturbation training or volitional motor-cognitive training, for example via senso, are currently being investigated.
Portable mats with integrated pressure sensors are also used, which are connected to a tablet, a screen or the TV at home and provide a playful training programme. This portable approach of “stepping training” has proven to be very practicable and effective in preventing falls (6).
Thanks to innovations such as these, the recording of step reaction time and the motor-cognitive training based on it can be used in prevention and the entire care process. It is not only available in clinics and specialised outpatient facilities. When implemented in everyday care, including as a test and training device for home visits, step reaction training becomes an interesting prospect for physiotherapy and for the healthcare of older people in general.
senso
Standing & Balancing
Therapy & Practice
THERAPY 2024-II
THERAPY Magazine
Miriam Keifert
Product Manager Clinical & Scientific, THERA-Trainer
Miriam Keifert has a degree in sports science
(M.Sc.) and
works in product management
of THERA-Trainer with the
specialising in "Clinical & Scientific".
References:
- Montero-Odasso M, et al. World guidelines for falls prevention and management for older adults: A global initiative. Age Ageing 51, 9: afac205; 2022
- Clark BC, et al. What is dynapenia? Nutrition 28, 5: 495-503: 2012
- Mirelman A, et al. Executive function and falls in older adults: New findings from a five-year prospective study link fall risk to cognition. PLoS ONE 7, 6: e40297; 2012
- Herold F, et al. Thinking while moving or moving while thinking – concepts of motor-cognitive training for cognitive performance enhancement. Front Aging Neurosci. 10: 228; 2018
- Beurskens R, et al. Age-related deficits of dual-task walking: A review. Neural. Plast. 2012: 1-9; 2012
- Sturnieks DL, et al. Exergame and cognitive training for preventing falls in community-dwelling older people: A randomized controlled trial. Nat. Med. 30, 1: 98-105; 2024
- Schättin A, et al. Adaptations of prefrontal brain activity, executive functions, and gait in healthy elderly following exergame and balance training: A randomized-controlled study. Front. Aging Neurosci. 8: 278; 2016
- Swinnen N, et al. The efficacy of exergaming in people with major neurocognitive disorder residing in long-term care facilities: A pilot randomized controlled trial. Alzheimers Res. Ther. 13, 1: 70; 2021
- Altorfer P, et al. Feasibility of cognitive-motor exergames in geriatric inpatient rehabilitation: A pilot randomized controlled study. Front Aging Neurosci. 13: 739948; 2021
- Jäggi S, et al. Feasibility and effects of cognitive–motor exergames on fall risk factors in typical and atypical Parkinson’s inpatients: A randomized controlled pilot study. Eur. J. Med. Res. 28, 1: 30; 2023
- Okubo Y, et al. Stepping impairment and falls in older adults: A systematic review and meta-analysis of volitional and reactive step tests. Ageing Res. Rev. 66: 101238; 2021