Body and brain – An inseparable team

Effectiveness of cognitive-motor training in neurology and geriatrics

Lars Timm

Getting up, shopping or going for a walk with friends: all of our everyday activities require the precise interaction of motor and sensory functions as well as the central nervous system. The brain, which is responsible for coordinating these subsystems, plays a central role. This interaction usually works perfectly in healthy, young people. In old age, after illnesses or accidents, people often find it difficult to interact optimally with their environment due to disturbances in the aforementioned subsystems or their coordination. This can lead to restrictions in everyday functioning and mobility and can even lead to falls and loss of independence.

Falls – Causes, consequences and prevention

In industrialised countries, one in three people over the age of 65 falls once a year on average. In the over-85 age group, the annual risk of falling increases to 50%. Falls among older people result in serious injuries in nearly 15% of those affected. These injuries lead to pain, a reduction in mobility and independence, and not infrequently an increased fear of falling. Furthermore, in addition to personal suffering, falls also lead to high costs for society and represent a socio-economic problem.

In medicine, a fall is defined as an accidental event resulting from loss of balance while standing or moving. The following degenerative changes are given in the literature as reasons for an increased risk of falling, which can be triggered by ageing processes, injuries or diseases:

• Changes in the motor system, e.g. reduced muscle mass/muscle strength
• Changes in the sensory system, e.g. impaired sensory perception
• Changes in the central nervous system, e.g. reduced signal conduction

Loss of muscle mass (sarcopenia) and muscle strength (dynapenia) are cited as the main causes of an increased risk of falling. Interestingly, dynapenia progresses faster than sarcopenia, so there is no linear connection. 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 [1].

For the complex process of walking, higher-order brain functions (cognitive processes) are required in addition to intact signal conduction and functional motor brain areas. Attentional and executive functions in particular are necessary for a safe gait pattern. Executive functions refer to cognitive abilities that enable goal-directed action (e.g. attention control). The executive functions are localised in the frontal lobe of the brain, which is subject to particularly strong degenerative changes during the ageing process. If age, illness or injury lead to an impairment of cognitive functions, this results in an increased risk of falls [2].

In “dual-task” paradigms in particular, it becomes obvious that walking requires cognitive resources. If a person is given a cognitive task such as arithmetic in addition to walking (dual-task condition), the gait pattern changes. The additional task requires resources that are no longer available to control walking. Dual-task interference, which can also be observed in healthy people, is intensified not only by ageing processes but also by neurological diseases [3].

Therefore, for successful fall prevention, training of cognitive functions must be considered in addition to improving muscle strength and balance.

Training the interaction between the body (motor and sensory system) and the brain is central here. Physical activity should therefore be combined with cognitive challenges. This type of training is increasingly known as cognitive-motor training [4].

Cognitive-motor training – Advantages and implementation

A new and particularly promising type of training focuses precisely on this combined concept. Interactive cognitive-motor training (also called dualtask training) couples movements with cognitive tasks. It simulates the demands of our daily lives and trains brain-body communication in a targeted way [4]. There is ample evidence in the research literature that cognitive-motor training is effective [5,6,7,8]. There are improvements in physical functions (e.g. balance, coordination, gait) but also in cognitive functions (e.g. attention or executive functions). It is also noted that cognitive-motor training can minimise the risk of falls in older people [9].

Researchers suggest that combined cognitive-motor training may lead to superior results compared to sequential training approaches. Findings from animal research confirm this assumption, which is caused by a synergistic effect [10]: Physical activity seems to trigger positive changes in the brain (neuroplastic effects) (e.g. the generation of new neurons), and cognitive challenge might be crucial to maintain these effects (e.g. integration of the new cells into the existing network).

Cognitive-motor training is suitable for anyone who wants to strengthen brain-body communication.

The senso was developed in cooperation with ETH Zurich, and enables such interactive cognitive-motor training in combination with exergames (exercise games). The user is presented with training games on a screen, each of which addresses specific brain functions. The games are controlled by means of body movements such as steps or shifts in balance. The movements are detected by a pressure-sensitive plate.

Fields of application and scientific evidence

Cognitive-motor training is suitable for anyone who wants to strengthen brain-body communication. It is used in prevention, as well as in therapy and rehabilitation. The senso is frequently used in the field of “active aging”, fall prevention and geriatrics as well as in neurorehabilitation.

Studies with healthy seniors in the context of fall prevention have shown that training on the senso improved the most important gait parameters (e.g. walking speed or stride length) [11,12]. These parameters are in turn directly related to a reduced risk of falling.

Cognitive-motor training on the THERA-Trainer senso is also suitable for use with neurological diseases such as dementia, Parkinson’s disease, stroke or multiple sclerosis. In a study with stroke patients, it was shown that both improvements in physiological parameters (e.g. gait pattern) and optimisation of brain functions (e.g. psychomotor speed) can be achieved through training with the THERA-Trainer senso [13]. In a study on patients with severe cognitive impairments in the context of dementia, positive effects of THERA-Trainer senso training were seen in walking speed and rapidity of step execution, in general cognitive status as well as psychological wellbeing [14].

In industrialised countries, one in three people over the age of 65 falls once a year on average. In the over-85 age group, the annual risk of falling increases to 50%.

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Sources:

[1] Clark, B. C., & Manini, T. M. (2012). What is dynapenia?. Nutrition, 28(5), 495-503.
[2] Mirelman, A., Herman, T., Brozgol, M., Dorfman, M., Sprecher, E., Schweiger, A., ... & Hausdorff, J. M. (2012). 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.
[3] Beurskens & Bock (2012). Age-related deficits of dual-task walking: a review. Neural plasticity, 2012
[4] Herold, F., et al., Thinking while Moving or Moving while Thinking-Concepts of motor-cognitive training for cognitive performance enhancement. Frontiers in aging neuroscience, 2018. 10.
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[6] Bamidis, P., et al., A review of physical and cognitive interventions in aging. Neuroscience & Biobehavioral Reviews, 2014. 44: p. 206-220. Beurskens & Bock (2012). Age-related deficits of dual-task walking: a review. Neural plasticity, 2012.
[7] Lauenroth, A., A.E. Ioannidis, and B. Teichmann, Influence of combined physical and cognitive training on cognition: a systematic review. BMC geriatrics, 2016. 16(1): p. 1.
[8] Law, L.L., et al., Effects of combined cognitive and exercise interventions on cognition in older adults with and without cognitive impairment: a systematic review. Ageing research reviews, 2014. 15: p. 61-75.Kempermann, G., et al., Why and how physical activity promotes experience-induced brain plasticity. Frontiers in neuroscience, 2010. 4: p. 189.
[9] Schoene et al. 2014 The effect of interactive cognitive-motor training in reducing fall risk in older people: a systematic review.
[10] Fabel, K. and G. Kempermann, Physical activity and the regulation of neurogenesis in the adult and aging brain. Neuromolecular medicine, 2008. 10(2): p. 59-66.
[11] de Bruin, E. D., Patt, N., Ringli, L., & Gennaro, F. (2019). Playing exergames facilitates central drive to the ankle dorsiflexors during gait in older adults; a quasi-experimental investigation. Frontiers in Aging Neuroscience, 11, 263.
[12] Schättin, A., Arner, R., Gennaro, F., & de Bruin, E. D. (2016). Adaptations of prefrontal brain activity, executive functions, and gait in healthy elderly following exergame and balance training: a randomized-controlled study. Frontiers in aging neuroscience, 8, 278.
[13] Huber, S. K., Held, J. P., de Bruin, E. D., & Knols, R. H. (2021). Personalized motor-cognitive exergame training in chronic stroke patients - A feasibility study. Frontiers in aging neuroscience, 13, 730801.
[14] Swinnen, N., Vandenbulcke, M., de Bruin, E. D., Akkerman, R., Stubbs, B., Firth, J., & Vancampfort, D. (2021). The efficacy of exergaming in people with major neurocognitive disorder residing in long-term care facilities: a pilot randomized controlled trial. Alzheimer’s research & therapy, 13(1), 1-13.

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Lars Timm
studied Sports Science with a focus on rehabilitation in Freiburg i.Br. and M.Sc. Sports Engineering at KIT Karlsruhe.