Comparison of the Effects of Dual Task Training and Action Observation Therapy Given to Geriatric Individuals
Comparison of the Effects of Dual Task Training and Action Observation Therapy Given to Geriatric Individuals
Summary Aging leads to significant declines in both motor skills and cognitive functions. Declines in walking, balance, and general mobility are particularly evident, while declines in cognitive functions such as attention, memory, and decision-making are also observed. It is crucial to recommend therapeutic interventions that support healthy aging, aim to increase physical and cognitive function, and prevent physical limitations in individuals over 65. The aim of this study is to examine the effects of dual-task training and action observation therapy on parameters such as cognitive function, balance, gait, functional mobility, flexibility, strength, and quality of life in geriatric individuals. Sixty-six individuals over the age of 65 will be randomized into the Dual-Task Training (DTT) group (n=22), the Action Observation Therapy (EGT) group (n=22), and the Control Group (CG) (n=22), which will receive conventional exercise. The exercise program will be applied 3 days per week for 8 weeks in all three groups. To assess balance and walking, the "Tinetti Balance and Walk Test" will be used; to assess functional mobility, the "Timed Up and Go Test" will be used; to obtain information about muscle strength, the "Hand Dynanometer" and the "5-Time Chair Sit-to-Stand Test" will be used; the "Sit-and-Reach Flexibility Test" will be used; to assess quality of life, the "CASP-19 Quality of Life Scale for Elderly People - Turkey Version (CASP-13)" will be used; to assess cognitive functions, the "Mini Mental State Test" and the "Clock Drawing Test" will be used; and perceived fatigue levels after exercise will be assessed using the Modified Borg Scale. The analyses of the data taken into the study will be carried out using SPSS (Statistical Program in Social Sciences). The values of the data will be expressed as numbers, percentages, mean and standard deviation; the significance level (p) will be taken as 0.05 for comparison tests.
Aging leads to significant declines in both motor skills and cognitive functions. While walking, balance, and general mobility are particularly impaired, cognitive functions such as attention, memory, and decision-making are also observed. The physical decline and cognitive decline associated with aging make it difficult for older adults to maintain independence in their daily activities. Studies have shown that cognitive impairments are directly related to mobility loss.
For individuals over 65, it is crucial to recommend therapeutic interventions that support healthy aging, aim to increase physical and cognitive function, and prevent physical limitations. In recent years, Action Observation Therapy (EGT), a cognitive strategy, has begun to be used in rehabilitation programs for the elderly, aiming to enhance motor learning and functional recovery. Action observation is a cognitive process based on observing actions performed by others without actually performing any movements. In EGT, participants first observe a meaningful action and then imitate it themselves. This stimulates motor learning and motor memory formation, facilitating the understanding and imitation of movements. EGT is a complementary strategy used to improve motor skills, facilitate motor learning, and stimulate neuroplasticity.
Another method used in recent years to improve motor skills and cognitive functions in the elderly is dual-task training (DTT). Dual-task training is based on the simultaneous execution of two motor-motor or cognitive-motor tasks. This methodology can be defined as the ability to simultaneously complete a secondary, cognitive, or motor task while maintaining the primary task of walking or postural balance.
A review of the literature has demonstrated that motor + cognitive dual-task training provided to elderly individuals is an effective intervention for improving cognitive function, health status, and life satisfaction, and reducing depression, in community-dwelling elderly individuals. Another study suggests that a dual-task intervention incorporating cognitive and physical activities in the elderly results in greater improvements in walking speed than interventions involving only physical activities. One study in the literature has reported that EGT improves cognitive function in individuals with MS. However, it appears that further research is needed on its effects on cognitive functions. A study published in 2025 reported that EGT, administered in addition to conventional treatment in elderly individuals, was effective in improving motor skills.
In light of this information, the investigators see that dual-task training and action observation therapy can be used to improve cognitive and physical functions in the elderly. However, it is also noteworthy that studies indicating that dual-task training can cause dual-task confusion in the elderly, leading to poorer performance. A review of the available literature reveals that studies on HDI and EGT mostly focus on a single disease, and no studies comparing these two methods, which may be effective in improving cognitive and motor functions in geriatric individuals, have been found.
More evidence is needed on outcome measures such as motor skills and cognitive functions for HDI and EGT in the geriatric population. Our proposed study will provide data and contributions to fill this gap in the literature.
Research question: In terms of the method used when implementing exercise programs in geriatric individuals, is conventional exercise training, dual-task training, or action observation therapy more effective on parameters such as cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life?
Hypotheses:
H0a: Dual-task training applied to geriatric individuals does not improve cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.
H0b: Action observation therapy applied to geriatric individuals does not improve cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.
Hypothesis H0c: There is no difference between the groups in terms of the effects of conventional exercise training, dual-task training, and action observation therapy applied to geriatric individuals on cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, or quality of life.
Hypothesis H1a: Dual-task training applied to geriatric individuals improves cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.
Hypothesis H1b: Action observation therapy applied to geriatric individuals improves cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.
Hypothesis H1c: There is a difference between the groups in terms of the effects of conventional exercise training, dual-task training, and action observation therapy applied to geriatric individuals on cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life.
Objectives: The aim of this study was to examine the effects of dual-task training and action observation therapy on parameters such as cognitive functions, balance, walking, functional mobility, flexibility, strength, perceived effort, and quality of life in geriatric individuals and to compare them with conventional exercise training.
Originality: There are studies demonstrating the use of dual-task training and action observation therapy to improve motor skills and cognitive functions in various diagnostic groups and in geriatric individuals. However, the investigators observe that there are more limited studies on the use of EGT in the elderly compared to HDI. The investigators believe that our study, which examines the effects of HDI and EGT on parameters such as motor skills and cognitive functions in geriatric individuals and compares these effects with conventional exercise training, will have a significant place in the literature. Our study aims to contribute to the literature by comparatively examining two different approaches that simultaneously intervene not only in motor skills but also in cognitive functions. Thus, it will provide insights into the holistic effects of different therapy methods on both motor skills and cognitive functions. The findings will provide recommendations for use in geriatric rehabilitation processes and help identify strategies that can improve overall health.
Type of Study This study is designed as a prospective experimental study. Location and Time of Study Data will be collected from nursing homes, nursing home elder care and rehabilitation centers, and Bahadın Elderly Living Center affiliated with the Ministry of Family and Social Services located in Yozgat and Çorum provinces. To avoid cross-contamination between the experimental and control groups, data for the experimental and control groups will be collected from different centers.
Research Population and Sample The sample for this study was determined using power analysis. According to calculations using the G*power 3.1.9.7 package program, with a total of 66 participants (22 in each group), an effect size of 0.40 and a significance level of 0.05, the power of the study will be 81.8%. This power is over 80%, making it sufficient. The sample will be selected from nursing homes, nursing home elder care and rehabilitation centers, and Bahadın Elderly Living Center affiliated with the Ministry of Family and Social Services located in Yozgat and Çorum provinces. These institutions will be listed, and three institutions will be selected from among the listed institutions, taking into account the high number of elderly individuals and their ability to meet the inclusion criteria. The groups to which geriatric individuals at these institutions will be assigned (HDE, EGT, and CG) will be determined using a sealed envelope method and randomized. Geriatric individuals at these institutions who meet the inclusion criteria and sign the informed consent form will be included in the study. A total of 66 participants will be selected, 22 geriatric individuals for each group.
Inclusion Criteria
The outcome measures listed below will be assessed using the specified scales during the initial and final evaluations.
Assessment of Cognitive Functions: Because elderly individuals must have adequate communication and cognitive status, their cognitive functions will be assessed using the "Mini Mental State Examination (MMSE)" for inclusion in the study. The highest possible total score is 30, and scores below 24 indicate cognitive impairment. Volunteers scoring 24 or higher on the MMSE will be accepted into the study. The adapted Turkish version of this scale, originally known as the "Mini-Mental State Examination (MMSE), will be used. The MMSE will be used not only as an admission requirement but also in the final assessment. In addition, the "Clock Drawing Test" will be used to test constructional praxis, comprehension, and planning abilities. The individual is asked to draw a clock, place numbers inside it, and mark the time as it is announced. A score below four is consistent with impaired cognitive function. Scoring is as follows: Writing 12 in the correct place: 3 points, Writing all twelve numbers: 1 point, Drawing the hour and minute hands: 1 point, Marking the announced time correctly: 1 point.
Balance and Gait Assessment: The "Tinetti Balance and Gait Test (TDYT)" will be used to assess the balance and gait of geriatric individuals. The TDYT was first developed by Mary Tinetti under the name Performance-Oriented Assessment of Mobility Problems in Elderly Patients (POMA) to evaluate patients at high risk of falling. It was later developed and named the "Tinetti Gait and Balance Assessment". The TDYT evaluates balance ability and gait under two main headings. The first 9 questions are about balance, and the total score is the balance score. The next 7 questions are about gait, and the total score is the gait score. Three values are assigned for each unit: 0-1-2. 2 points represent correct performance of the specified movement; 1 point represents correct performance of the specified movement; A score of 0 indicates that the specified movement is performed with adaptations, and a score of 0 indicates that the movement cannot be performed. The sum of the balance and walking scores provides the total score. The total balance score is 16; a score below 11 indicates a risk of falling. The total walking score is 12; a score below 8 indicates a risk of falling. The Turkish validity and reliability study of the scale was conducted by Ağırcan.
Functional Mobility Assessment: The Timed Up and Go test (TUG) is a practical, equipment-free method that can be used to measure functional mobility in older individuals.
The individual being assessed stands up from a sitting position of approximately 46 cm, walks 3 meters, returns, and sits down again. The test is repeated twice. The elapsed time is measured in seconds .
Muscle Strength Assessment: Grip strength will be measured with a handheld dynamometer to obtain information about the general muscle strength of geriatric individuals. The study plans to measure hand muscle strength using a "Hand Dynamometer." During the measurement, the participant will be seated upright, as recommended by the American Association of Hand Therapists (AETD), and arm support will not be allowed on the sitting surface . Measurements will be performed three times, 10 seconds apart, and the average value will be used in the study. The measured force will be recorded in kg. Additionally, the "5-Time Chair Sit-to-Stand Test" (5KSOKT) will be used to assess lower extremity strength. In this test, the patient sits with their arms crossed over their shoulders and their back against a chair. On the "Start" command, the patient stands up and sits down quickly from a standard chair five times. The elapsed time is measured with a stopwatch .
Flexibility Assessment: The sit-and-reach flexibility test will be used to assess flexibility. The subject is seated on a flat surface, the soles of their bare feet are placed flat on the test bench, and then the subject is asked to extend their trunk forward as far as they can, holding the arms and fingers tense and straight for one or two seconds at the end position. After two attempts, the best score is recorded .
Quality of Life Assessment: The quality of life of geriatric individuals will be assessed using the "CASP-19 Elderly Quality of Life Scale - Turkish Version (CASP-13)." The CASP-19 Scale was developed by Hyde and colleagues to measure the quality of life of older adults. The CASP-13 Scale is the Turkish translation of the CASP-19 Scale and its adaptation for Turkish elderly. The validity and reliability study of the scale for Turkish elderly was conducted by Türkoğlu et al. The CASP-13 scale, the Turkish version of CASP-19, consists of 13 items. The questions are scored as 0 for "never," 1 for "occasionally," 2 for "sometimes," and 3 for "always." The scale score ranges from 0 to 39. A higher total score indicates an increase in quality of life. The positively worded items 3, 5, 6, 7, 8, 9, 10, 11, 12, and 13 constitute factor 1 (perception of autonomy and satisfaction), while the negatively worded and reverse-coded items 1, 2, and 4 constitute factor 2 (perception of disability). Cronbach's alpha coefficient of the scale was reported as 0.91. Assessment of Perceived Fatigue: Geriatric individuals' perceived fatigue levels after exercise will be assessed using the Modified Borg Scale (MBS). This scale was developed by Borg in 1970 to measure the effort expended during physical exercise . The MBS consists of 10 points indicating dyspnea severity. A score of 0 indicates no dyspnea or fatigue, while a score of 10 represents the highest degree of dyspnea and fatigue. Measurements will be taken after the first session of week 1 and the last session of week 8 for geriatric individuals in each group.
Study Design After obtaining informed consent for participation in the study, all participants, regardless of group, will undergo a pre- and post-intervention assessment by an experienced physiotherapist before group assignment. Following the pre-test assessments, patients will be informed about their groups and the relevant interventions will begin. The exercise program and cognitive tasks will be progressed every two weeks. The number of repetitions and sets will be adjusted as the exercise program progresses. Exercise sessions will be conducted three days per week for a total of eight weeks. Individuals in the HDI group will perform a cognitive task in addition to the conventional exercises. The cognitive tasks were determined based on a literature review. Individuals in this group will watch videos of exercises on a computer screen in three periods (in bed, sitting, and standing). Each exercise in each period will be viewed for 2 minutes and performed for 1 minute under the supervision of a physiotherapist. The EGT protocol was developed based on a review of literature. The CG will perform conventional exercises. Participants Geriatric individuals who meet the specified inclusion and exclusion criteria will be included in the study. Participants will be included in the study after signing a voluntary informed consent form.
Interventions Dual Task Training (DTT) Group: Individuals in this group will perform exercise sessions consisting of cognitive tasks combined with conventional exercises, 3 days a week, for a total of 8 weeks, under the supervision of a physiotherapist. Each session will last an average of 40-50 minutes.
Action Observation Therapy (EGT) Group: Individuals in this group will watch exercises on a computer screen in 3 periods (in bed, sitting, and standing). Each exercise in each period will be observed for 2 minutes and performed for 1 minute under the supervision of a physiotherapist. There will be a 1-minute break between periods. Each session will last an average of 40-50 minutes. Control Group (CG): Individuals in this group will perform conventional exercise sessions under the supervision of a physiotherapist three days a week for a total of eight weeks. Each session will last an average of 40-50 minutes.
Randomization In this study, to prevent any cross-contamination between the experimental and control groups, data for the experimental and control groups will be collected from different centers. To this end, after obtaining the necessary permits from the Ministry of Family and Social Services in Yozgat and Çorum provinces, and from the Bahadın Elderly Living Center in Yozgat province, the nursing homes, elderly care and rehabilitation centers, and elderly living centers in these provinces will be listed. Three institutions will be selected from the listed institutions, taking into account the large number of elderly individuals and whether they meet the inclusion criteria. The groups to which geriatric individuals in these institutions will be assigned-HDE, EGT, and CG-will be determined using a sealed-envelope method and randomized. Geriatric individuals who meet the inclusion criteria and sign the informed consent form will be included in the study. A total of 66 participants will be selected, 22 for each group, of whom 22 will be geriatric.
Exercise Protocol Based on the World Health Organization (WHO) exercise recommendations for older adults, the researcher has developed an exercise protocol suitable for participants over the age of 65, including balance, strengthening, and flexibility exercises performed in various positions, such as lying down, sitting, and standing. The exercises, prepared in accordance with World Health Organization recommendations, were developed by a physiotherapist experienced in geriatric rehabilitation. The exercise training program is designed to be performed three days a week. To facilitate patient comfort, the program will begin with exercises in the supine and prone positions and progress to exercises in the sitting and vertical positions. Each exercise session will consist of a warm-up (5 minutes); balance, flexibility, general muscle strengthening, and walking (30-40 minutes); and a cool-down (5 minutes). Each session will last 40-50 minutes.
Week 1: After randomization, the sample groups will be introduced. Information about the study will be provided. A seminar will be held on the benefits of physical activity in the elderly, and motivating individual training schedules will be presented to participants.
Week 2: Initial assessments of outcome measures will be conducted. Weeks 3-4: All three groups will begin training with warm-up exercises (5 minutes). Then, exercises including flexibility, strengthening, balance, and walking will begin (30-40 minutes). The session will conclude with cool-down exercises (5 minutes).
Weeks 9-10: All 3 Groups will begin training with warm-up exercises (5 minutes). Then, they will begin performing exercises that include flexibility, strengthening, balance, and walking exercises (30-40 minutes). The session will conclude with a 5-minute cool-down exercise. The number of repetitions/sets will be progressive.
Week 11: Final assessments of outcome measures will be made. Pre-Exercise Warm-Up and Post-Exercise Cool-Down Exercises
Warm-Up Exercises (5 min)
Side Stepping
Touching the right and left legs while standing
Reaching the arms to the right and left while standing
Shoulder Rolls and Neck Movements Cool-Down Exercises (5 min)
Step-Up
Rotating the waist to the right and left with hands on hips
Tightening and then relaxing the entire body while standing with eyes closed
Shoulder Rolls and Neck Movements 8-Week Conventional Exercise Protocol to be Used in the Study EXERCISES
Say 3 words, but only repeat the vegetable words. Count backward from 100 by 5s. Generate words related to the specified category that contain 2 specified letters.
Say numbers between 1 and 100 whose sum is 10. Say the digits of a 4-digit number in reverse order.
Inclusion Criteria:
Exclusion Criteria:
g.gul.turan@yobu.edu.tr+90 507 778 91 60
fatma.kizilay@inonu.edu.tr+90 532 411 68 47
Yozgat, Yozgat / Central 66100, Turkey (Türkiye)
g.gul.turan@yobu.edu.tr+90 507 778 91 60
fatma.kizilay@inonu.edu.tr+09 532 411 68 47