Discussion
dementia, cognitive impairment
In this study, we investigated the effects of a community-based, structured exercise program combined with action observation on strength, balance, mobility, and cognition in healthy older adults who were socially isolated during the pandemic. We applied a combined exercise program with Action Observation Training (AOT) to one group, and exercise alone to the other group and compared the effect of both programs. We observed significant improvements in all outcome measurement results in both AOT and simple exercise groups after the intervention, thus confirming the effectiveness of our community-based training method. Comparing post-intervention improvements between groups, we further found that the progress effect size in the group with AOT was significantly stronger in all outcome measures, except for cognitive abilities (MoCA). Thus, our hypothesis that AOT would increase the effectiveness of the exercise program was partly confirmed. We used the Montreal Cognitive Assessment (MoCA) as our assessment tool for evaluating cognitive function in the study participants. The MoCA is a widely recognized instrument known for its sensitivity in detecting cognitive changes, particularly in individuals with mild cognitive impairment or early stages of dementia. However, it’s important to acknowledge that MoCA’s sensitivity can be influenced by various factors, including practice effects, which may impact the interpretation of scores when used as an outcome measure in repeated assessments.The study’s context is crucial in understanding the challenges and potential impact of our interventions. It has been demonstrated that older adults’ physical activity levels correlate strongly with the time they spend outdoors [In light of previous research findings, community-based interventions tailored to older adults and incorporating face-to-face or group sessions tend to yield greater effectiveness [A step-reduction study has shed light on the detrimental effects of short-term (14 days) physical inactivity on both the metabolic and musculoskeletal systems [Drawing parallels to a similar study by Leem et al. involving older adults, where the effects of action observation (lasting 20 minutes) and simple Otago exercises (comprising strength and balance exercises) were compared, our findings align with prior research. Despite the shorter total number of sessions in our study (24 sessions), Group I, which received AOT, experienced a more substantial increase in muscle strength. This improvement was not only statistically significant but also clinically more pronounced, as indicated by the effect size Cohen’s-d (1.09 for Group I vs. 0.34 for Group II). These results provide further support for previous evidence suggesting that the action observation technique accelerates motor learning and enhances motor skills, leading to improved muscle strength [The impact of Action Observation Therapy (AOT) on balance performance in healthy populations has been a subject of investigation in previous studies. For instance, Gatti et al. conducted research on 79 healthy young adults, dividing them into action observation, action observation plus imitation, balance training, and control groups. These groups underwent daily 30-minute training sessions over three weeks, and posturography was used for evaluation. Their findings indicated that both action observation plus imitation and balance training had comparable effects in enhancing postural control, with even action observation alone showing a tendency to improve postural control [In our study, the mean baseline scores of our participants on the Tinetti test, which quantifies balance, indicated a high risk of falling (≤18 points). However, our results demonstrate the effectiveness of the exercise program we implemented in improving the participants’ balance skills. Following the training, we observed significant enhancements in the balance, walking, and total scores of the Tinetti test in both study groups, resulting in a reduction of the risk of falling to an intermediate level (19–23 points). Furthermore, when comparing post-intervention improvements between the groups, we noted that the progress measured in AOT Group-I was significantly greater in terms of all three Tinetti test scores (balance, walking, and total). Notably, the effect of this change was clinically more pronounced (Cohen’s-d: 1.28, 0.86, 1.25, respectively for Group-I vs. 0.58, 0.39, 0.55 for Group-II). Additionally, the self-reported balance confidence scale (ABC test) showed a baseline mean value for our study participants indicative of a low functional status (<60%). Nevertheless, after the training, it significantly improved in both groups, surpassing the threshold value. This improvement in effect size was also notably stronger in the AOT Group-I (Cohen’s-d 0.91 for Group-I vs. 0.37 for Group-II). These findings are of paramount importance as they underscore the enhancement of exercise training benefits by action observation therapy, particularly in improving multidimensional skills such as balance.We selected the Timed Up and Go (TUG) test to assess the mobility of our participants, a test that is positively correlated with age. Normatively, it is expected to be approximately 9.4 seconds for individuals over 65 years of age [In our study, we aimed to investigate the potential cognitive benefits of a multicomponent program that included community-based outdoor activities, group exercise, social participation, and the mental strategy of action observation. We employed the Montreal Cognitive Assessment (MoCA) to evaluate cognitive function among participants. At baseline, none of our participants exhibited cognitive impairment, as indicated by MoCA scores ≥21 points. However, none of them achieved a perfect score, suggesting room for improvement in cognitive function (maximum observed score: 28<30). Upon completion of our study, both groups showed small but statistically significant improvements in MoCA assessments. However, there was no significant difference between the groups favoring the Action Observation Therapy (AOT) group. Furthermore, the observed improvements, though statistically significant, were of minimal clinical significance, with effect sizes (Cohen’s-d) below 0.2. Surprisingly, our exercise program, even with the inclusion of AOT, did not yield substantial enhancements in cognitive abilities. Several factors may explain these results. First, our participants had cognitive reserves within the normal range, which might have limited the potential for cognitive improvement. Additionally, the relatively low exercise intensity and the emphasis on cognitive task training during our sessions could have contributed to these findings.There is limited existing literature on the effects of AOT on cognitive functions, with only one trial specifically examining this aspect. In that study, the combination of action observation and gait training was investigated in individuals with mild cognitive impairment, reporting better progress in MoCA scores and improved cognition along with enhanced walking performance [