Eligibility and Study Design
A single-blind, randomized, and controlled clinical trial compared the effects of TIM, a co-dependent motor-cognitive intervention, and CogniFit, a single modality computerized cognitive training (control), on cognition and gait quality in 47 community-dwelling older adults who attend an adult day center (based on G power calculation on the main outcome cognitive performance). Potential participants were recruited through referrals from day center staff members. Inclusion criteria were: (1) age over 65; (2) ability to walk independently with or without an assistive device; (3) ability to understand simple instructions and sign an informed consent form; (4) ability to commit to the program based on a short interview. This set of minimum criteria seeks to represent as reliably as possible the population of the day centers as it is, although indeed, some of the participants demonstrated cognitive decline without a documented dementia diagnosis. Participants who met the inclusion criteria were randomly assigned to an eight-week, thrice per week, 40-minute intervention in one of two groups: TIM group intervention (n=28) or individual computerized cognitive training using CogniFit training (n=19) (i.e., control group). Randomization was conducted using a random number table. Baseline assessment was conducted by a research assistant, naive to participant assignment, and included: (1) demographic and psychological measures: The Geriatric Depression Scale (GDS)23, Short Anxiety Screening Test (SAST)24 and the Activities-specific Balance Confidence (ABC) Scale25; (2) cognitive performance: Montreal Cognitive Assessment; MoCA26 and a computerized neuro-cognitive assessment using CogniFit battery27 and (3) gait assessment in single and dual-task conditions using an accelerometer and gyroscope mounted on the waist from McRoberts Mobility Lab28. Cognitive and gait evaluations were conducted again after eight weeks of intervention. The study protocol was approved by an institutional review board. All participants signed a consent form and did not receive any monetary compensation for participation.
Thinking in Motion (TIM) intervention
TIM is a combined motor-cognitive co-dependent intervention inspired by the Eshkol-Wachman Movement Notation (EWMN), which uses graphic symbols to describe motion.29 Unlike the fixed use of graphic symbols in EWMN, TIM separates from the permanent system of symbols and uses the ephemerality of symbols and frequent changes in them as a central tool for cognitive stimulation. The ephemerality and frequent changes require a renewed learning process, coping with coding permanence and mental flexibility. In addition, the use of symbols creates the cognitive challenge of producing movement from interpreting a graphic sign, i.e; visual scanning, information processing, and spatial perception. The symbols represent various components in movement such as organ movement, landmarks in space, time, and rhythm elements. After establishing the given symbols for the exercise, a cognitive challenge is graded by a constant change of the symbols’ order. The TIM trainer uses a “manipulation bank” that is applied to various components of the movement or how they are presented graphically. The chosen manipulations enable the TIM trainer to manage the level of difficulty and the variety of cognitive skills required to perform them. An example of TIM training and manipulation options is shown in Figure 1.
Control group- CogniFit intervention
CogniFit is a computerized cognitive training which was found to be effective in improving cognition and gait.5-22 The program is personally tailored based on a 45-minute baseline assessment.27 Each training session includes a mixture of auditory, visual, and cross-modality tasks aimed at training executive functions, attention, and other cognitive processes. Verbal instructions were written on the screen before each task and then demonstrated by the program30. Technical support in operating the software and assistance in understanding the tasks were available.
Outcome Measures Assessments
Measures were undertaken at baseline and after the eight-week intervention. All assessments were conducted by a blinded research assistant.
Primary Outcome: Cognitive Functions-
The 40-minute CogniFit computerized neurocognitive assessment battery27 was used to evaluate changes in cognitive function following both interventions. Apart from the global score, the cognitive indicators examined in this study were working memory, divided attention, processing speed, and visual scanning.
Secondary Outcome: Gait Performance-
Gait measures included gait speed and stride time variability collected under ST and DT conditions with the McRoberts Mobility Lab, an accelerometer and gyroscope attached to the participants’ waists.31 Gait tasks took place for periods of one minute along a six-meter route in a quiet room. The cognitive task attached to the walking was subtraction by 3 from a random number between 100 and 250.32 The order of the tasks was randomized.
All analyses were performed using SPSS 26 (IBM SPSS Statistics, New York, US). Continuous data are presented as mean and standard deviation or median and interquartile range, while categorical data are presented as frequencies (percentage and number of participants). Between-group differences in demographic data were analysed via Mann-Whitney U tests, Pearsons' chi-square test, or Fisher's Exact tests. CogniFit measures at baseline and post-intervention were examined using between-within repeated measures Analysis of variance (ANOVA) and presented as mean ± standard error. When an interaction was significant, it was followed by t-test post-hoc analyses. Gait outcomes were speed and stride time variability. Effect size estimator was partial eta-squared (ηp2) for the ANOVA test. Effect sizes are reported for significant comparisons only.