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Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to Improve Brain and Cognition in Healthy Older Adults? Data-Based Viewpoint

Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to... Combining physical, motor, and cognitive exercises is expected to be effective to attenuate age-related declines of brain and cognition in older adults. This can be achieved either by conventional interventions or by exergames. This paper aimed to determine whether conventional combined training and exergame interventions are two comparable ways for delivering combined training. In total, 24 studies on conventional training and 23 studies on exergames were selected and compared. A common framework was used to analyze both types of combined training interventions. Our analysis showed that conventional combined training interventions were more effective than separated physical and motor training to improve brain and cognition, while their superiority over cognitive training alone remains to be confirmed. Exergames scarcely led to cognitive benefits superior to those observed after physical, motor, or cognitive training alone. Thus, although both conventional training interventions and exergames allowed delivering combined training programs, they are not two facets of the same coin. Further studies that are more theoretically grounded are necessary to determine whether interventions delivered via exergames may lead to superior benefits compared to conventional separated and combined training interventions. (JMIR Serious Games 2022;10(4):e38192) doi: 10.2196/38192 KEYWORDS aging; older; gerontology; exergame; physical activity; cognition; training; intervention; cognitive; brain; older adult; motor skills; exercise; physical; motor; combined training effective than conventional combined training programs, since Introduction they conjugate the effects of physical and motor exercises [1,7] and those of video game training on cognitive performance Delaying or attenuating age-related cognitive decline is critical [8,9]. However, until now, no study has systematically for preserving autonomy and quality of life of the increasing compared, within the same experimental protocols, the number of older adults. It has been widely demonstrated that respective benefits of ‘conventional’ CTIs and exergames with separate cognitive, aerobic, muscular, and motor training are regard to cognitive outcomes in healthy older adults. “A review effective in this respect [1]. Moreover, it has been suggested of reviews” (ie, 3 reviews on conventional cognitive and motor that their integration into combined training interventions (CTIs) training and 3 on exergames) [10] recently addressed this issue might be more effective than separated training [2-4]. In this and reported conflicting results. Specifically, the benefits of context and in view of the role played by cognitive stimulations conventional CTIs were found superior to those of separated in CTIs [5,6], exergames (ie, interactive video games that require training in 2 reviews, but the superiority of exergames over participants to be physically active to play) might be even more https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre physical or cognitive training alone was unclear in the selected framework developed in 2 recently published review papers reviews. dedicated to conventional CTIs [11] and exergames [12], we compiled the data of 47 studies to compare randomized This paper aims to go a step further by reporting the results of controlled trials and controlled trials that have used either a detailed comparison of studies that used conventional CTIs conventional combined training or exergames to improve and those that used exergames to improve brain and cognition cognitive functions (Table 1 and Table 2). in healthy older adults. To fulfill this objective, based on the Table 1. Selected reviews and studies on conventional combined training interventions. Studies were classified as a function of the type of combined intervention. Conventional combined Studies training interventions Reviews Law et al [13], Wollesen and Voelcker-Rehage [14], Zhu et al [15], Lauenroth et al [3], Levin et al [16], Tait et al [17], Gheysen et al [2], Joubert and Chainay [18], Gavelin et al [19], Wollesen et al [20], Gallou et al [10], Gou et al [21] Studies Sequential Fabre et al [22], Legault et al [23] PCT Shatil et al [24], Linde and Alfermann [25], Shah et al [26], Mc Daniel et al [27], Desjardins-Crépeau et al [28] Oswald et al [29] MCT Pieramico et al [30], Van het Reve and de Bruin [31], Rahe et al [32], Rahe et al [33], Kalbe et al [34] MDT Simultaneous PCT Theill et al [35], Leon et al [36], Norouzi et al [37], Eggenberger et al [38], Eggenberger et al [39] MCT Hiyamizu et al [40], Marmeleira et al [41], Falbo et al [42] MDT Ansai et al [43], Yokoyama et al [44], Nishiguchi et al [45], Jardim et al [46] PCT: physical-cognitive training. MCT: motor-cognitive training. MDT: multidomain training. Table 2. Selected reviews and studies on exergames. Studies were classified as a function of the type of combined intervention. Exergames interventions Studies Reviews Zhang and Kaufman [47], Bleakley et al [48], Ogawa et al [49], Howes et al [50], Stanmore et al [51], Vázquez et al [52], Mansor et al [53], Stojan and Voelcker-Rehage [54], Gallou-Guyot et al [10], Wollesen et al [20], Gavelin et al [19], Sakaki et al [55], Soares et al [56] Studies Sequential a b PCT — Park and Yim [57] MCT Kayama et al [58] MDT Simultaneous PCT Anderson-Hanley et al [59], Barcelos et al [60] MCT Schoene et al [61], Schoene et al [62], Gschwind et al [63], Schättin et al [64], Adcock et al [65], Carrasco et al [66], Eggenberger et al [39], Eggenberger et al [67], Huang [68], Li et al [69] MDT Maillot et al [70], Chuang et al [71], Ordnung et al [72], Guimaraes et al [73], Htut et al [74], Bacha et al [75], Peng et al [76], Moreira et al [77], Gouveia et al [78] PCT: physical-cognitive training. Not available. MCT: motor-cognitive training. MDT: multidomain training. https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre Accordingly, 3 main training modes were distinguished: (1) A Structured Framework for Analyzing physical-cognitive training (PCT), which correspond to the Combined Training Interventions association of endurance (aerobic) and muscular resistance training and cognitive training, either sequentially or We developed a framework to analyze CTIs, independent of simultaneously; (2) motor-cognitive training (MCT), which whether they were delivered via conventional interventions or refers to the association of complex motor skills training and via exergames. Specifically, we distinguished the following: cognitive training, implemented through the addition of (1) the stimuli, which refer to different types of combined cognitive tasks separated from the motor tasks (eg, mental training; (2) the settings, which are the organizing features of calculation); and (3) multidomain training (MDT), which training programs (ie, frequency, duration, intensity, instructions, consists of associating aerobic exercises, complex motor skills, feedback, individualization, and progressivity of increase in and cognitive tasks through laboratory-customized training difficulty); (3) the targets of training, which were limited in this situations. Notably, for conventional CTIs, we limited our review to brain and cognitive levels, but other levels could be analysis to randomized controlled trials and controlled trials in added in future works; (4) the markers, that is, the tasks and which it was possible to identify different training components tests used to train or assess the participants, respectively; (5) (ie, physical, motor, and cognitive) that were associated with the outcomes of different types of training, that is, the different each other. Thus, according to this criterion, interventions variables that allow for quantifying the observed effects at brain implemented through natural motor activities (eg, tai chi, dance, and cognitive levels; (6) the moderators, who modulated the or Nordic walking) were excluded. Although these activities effects of training; and (7) the potential mechanisms, which included physical, motor, and cognitive components, their were explicitly mentioned in different studies to predict and respective weights and levels of intensity or complexity were explain the effects of combined training (Figure 1). difficult to quantify. Based on this framework, in this study, we focused our comparative analysis on the following 4 main constructs: stimuli, settings, targets, and outcomes. Figure 1. A multidimensional framework to analyze combined training interventions (detailed explanations are presented in a previous study [11]). Published under Creative Commons Attribution 4.0 International License. https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre whereas it was the case in only 1/23 (4.3%) of the exergames The Database studies. Most frequently, exergames studies included 2 groups, that is, either a passive control group (9/23, 39.1%), a physical Our analysis was grounded on the material included in 2 recently or motor training group (13/23, 56.5%), or less frequently, a published reviews dedicated to conventional CTIs [11] and cognitive training group (2/23, 8.6%), in addition to the exergames [12], respectively. Specifically, 24 studies on exergaming group. In both conventional CTI and exergames conventional training and 23 studies on exergames, published studies, permanence and transfer of training effects were from 2010 to November 2021, were selected on the basis of scarcely investigated, so no reliable conclusion can be drawn several criteria [11,12]. These studies were then analyzed to in this respect. compare them according to the 4 chosen constructs of our framework (Table 1 and Table 2). Targets No main difference was observed between the cognitive abilities Quantitative and Qualitative Differences tested in conventional CTIs and exergames studies. The most Between Conventional Interventions and frequently tested were memory, executive functions, attention, and information processing speed, but there were no ‘a priori’ Exergames assumptions about the type of functions that could be affected more or less by each CTI. The respective effects of conventional Stimuli combined training and exergames on brain health and Motor and cognitive exercises were performed simultaneously neurobiological mechanisms cannot be reliably compared due in 100% (n=23) of the exergames studies, whereas sequential to the small number of related studies and their heterogeneity presentation of physical and cognitive exercises was used in (ie, 4 and 2 studies, respectively). 58% (7/12) of conventional PCT studies, 22% (2/9) of MDT studies, and 50% (2/4) of MCT studies. Thus, one can Outcomes hypothesize that several studies on conventional CTIs used Combined Training Versus Passive Control Groups mechanisms that were different from those involved in exergame interventions. Another important issue concerns the distribution Independent of the training modes (ie, PCT, MCT, or MDT), of the 3 training modes (ie, PCT, MCT, and MDT), which positive effects were observed, relative to passive control differed in conventional CTI and exergames studies. Indeed, groups, in all conventional CTIs and exergames studies, for at the proportion of PCT studies was much higher for conventional least one of the targeted cognitive functions, that is, memory, interventions compared to exergaming (12/24, 50% and 2/23, attention, executive functions, and information processing speed. 8%, respectively), whereas the inverse was observed for MCT These results were observed for both sequential and 16% (4/24) for conventional interventions and 47% (11/23) for simultaneous associations between cognitive and physical or exergaming, respectively) and MDT studies 37% (9/24) for motor exercises. Unfortunately, it was impossible to determine conventional studies and 43% (10/23) for exergaming, whether cognitive functions were differently impacted by respectively). This resulted from the predominant use of conventional combined training and exergames, respectively. commercial exergames (eg, Xbox Kinect and Wii Balance These results are consistent with those reported by Gallou-Guyot Board), which were cheaper than the stationary cybercycle used et al [10]. Unsurprisingly, they suggest that regardless of how for implementing PCT in exergames studies [59,60]. It could combined training is delivered (ie, conventional interventions be concluded from the distribution of PCT in both conventional or exergames, and PCT, MCT, or MDT), combined training and exergaming intervention studies that, on average, the latter programs always lead to superior benefits compared to was less physically demanding than the former; supporting inactivity. evidence could be found in a study by Graves et al [79], and a Combined Training Versus Physical Training discussion is presented in Gonçalves et al’s 2021 study [80]. In conventional CTIs, superior benefits of combined training However, this issue is a matter of debate, since few studies over separated physical training were observed in 100% (n=13) demonstrated that commercial exergames can be the support of of MCT and MDT studies and in most of the PCT studies (8/12, intense physical activity [81,82], whereas others showed that 66.6%). On the other hand, superior benefits of exergaming they only facilitated light- to moderate-intensity physical activity compared to conventional physical or motor training alone were [83]. On the other hand, since commercial exergames usually observed in only one study on exergames [59], whereas no required upper limb movements, whole body movements, difference was found between the exergames and separated stepping, weight shifting or balance control, motor exercises training groups in the 4 other studies (2 on MCT and 2 on supporting MCT and MDT in conventional CTIs and exergames MDT). studies were roughly similar. Combined Training Versus Cognitive Training Settings In conventional training studies, compared to cognitive training Conventional CTIs most frequently aimed to compare several alone, superior benefits of CTIs were observed in almost groups simultaneously. Indeed, 21/24 (87%) involved a passive one-third of PCT studies (n=4), but never in MCT and MDT control group, alone or together with cognitive training (15/24, studies. In the 2 studies that compared exergaming and cognitive 62%) and physical or motor training (13/24, 54%) groups. In training, one reported a superiority of the former over the latter total, 8/24 (33%) of the conventional training studies involved on executive functions [67], whereas the other did not [74]. 3 training groups (ie, CTI, physical or motor, and cognitive), https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre Thus, the number of related studies was too small to draw exergames did not allow reaching high enough levels of physical reliable conclusions about the superiority of exergames over effort [10] or motor skills complexity, and they used the cognitive training alone. resources of virtual reality and video games insufficiently to improve the cognitive load of different exercises [84]. This is Limitations and Study Comparisons not to say that exergame interventions cannot succeed in being more effective than conventional CTIs. However, further studies, The studies including 4 training groups (ie, combined training, grounded on theoretical knowledge provided by the literature separated physical and cognitive training, and a control group), on physical, motor, and cognitive training are necessary to which could allow for a complete comparison, were scarce (ie, determine whether interventions delivered via exergames may 8 conventional training studies out of 47, in total). A second lead to superior benefits compared to separated and combined observation was that despite the type of intervention (ie, CTIs. In particular, since commercial exergames are not conventional or exergames), the mechanisms underlying designed specifically for older adults, exergames studies should eventual differences with physical and cognitive training groups use new solutions that are more grounded on theoretical were rarely addressed in the reviewed studies. A third foundations [84]. observation was that information relative to intensity and the Finally, this analysis showed that conventional CTIs and nature of physical exercises, the nature and levels of complexity exergames studies did not address the same research questions, of motor exercises, and progressivity of difficulty was neglected thereby precluding reliable comparisons of their benefits. in most studies, so it was impossible to estimate why physical Specifically, conventional CTI studies prominently aimed to or motor training was effective (or not) to improve physical, compare benefits of separate training programs, whereas motor, or cognitive performance. This was the case, in particular, exergames studies focused on the benefits of exergaming per in exergames studies. In addition, in several studies, cognitive se, most often relative to inactive control groups. Thus, training procedures and (exer)game contents were not described contrarily to our expectations, they seem to be separated or were only superficially described. Finally, due to the small domains of the literature on aging, which, until now, have number of studies available to support some comparisons (eg, developed independently of each other. In particular, the exergames and cognitive training; conventional CTI vs literature on exergames has not yet reached the level of maturity exergames), the results remain to be confirmed or even of those on conventional CTIs, which itself remains established in future studies. heterogeneous and suffers from methodological weakness and lack of a strong conceptual background [11,84,85]. Therefore, Discussion although they both allow for delivering combined training programs, conventional and exergames interventions are not In this paper, we aimed to determine whether conventional CTIs two facets of the same coin; rather, they are two coins we do and exergames were two comparable ways for delivering not know which is more valuable. Accordingly, future studies combined training. Our analysis showed that conventional CTIs should aim to develop new exergames that would capitalize were more effective than separated physical and motor training more on the knowledge from studies on conventional CTIs, to improve brain and cognition, but their superiority over particularly concerning the underlying mechanisms. These cognitive training alone remains to be confirmed in further studies should also systematically compare the effectiveness of studies. 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[doi: 10.1016/j.arr.2018.04.002] [Medline: 29679658] Abbreviations CTI: combined training intervention MCT: motor-cognitive training MDT: multidomain training https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre PCT: physical-cognitive training Edited by N Zary; submitted 22.03.22; peer-reviewed by M Gallou-Guyot; comments to author 21.07.22; revised version received 22.07.22; accepted 04.08.22; published 03.10.22 Please cite as: Temprado JJ, Torre MM Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to Improve Brain and Cognition in Healthy Older Adults? Data-Based Viewpoint JMIR Serious Games 2022;10(4):e38192 URL: https://games.jmir.org/2022/4/e38192 doi: 10.2196/38192 PMID: ©Jean-Jacques Temprado, Marta Maria Torre. Originally published in JMIR Serious Games (https://games.jmir.org), 03.10.2022. 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Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to Improve Brain and Cognition in Healthy Older Adults? Data-Based Viewpoint

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Abstract

Combining physical, motor, and cognitive exercises is expected to be effective to attenuate age-related declines of brain and cognition in older adults. This can be achieved either by conventional interventions or by exergames. This paper aimed to determine whether conventional combined training and exergame interventions are two comparable ways for delivering combined training. In total, 24 studies on conventional training and 23 studies on exergames were selected and compared. A common framework was used to analyze both types of combined training interventions. Our analysis showed that conventional combined training interventions were more effective than separated physical and motor training to improve brain and cognition, while their superiority over cognitive training alone remains to be confirmed. Exergames scarcely led to cognitive benefits superior to those observed after physical, motor, or cognitive training alone. Thus, although both conventional training interventions and exergames allowed delivering combined training programs, they are not two facets of the same coin. Further studies that are more theoretically grounded are necessary to determine whether interventions delivered via exergames may lead to superior benefits compared to conventional separated and combined training interventions. (JMIR Serious Games 2022;10(4):e38192) doi: 10.2196/38192 KEYWORDS aging; older; gerontology; exergame; physical activity; cognition; training; intervention; cognitive; brain; older adult; motor skills; exercise; physical; motor; combined training effective than conventional combined training programs, since Introduction they conjugate the effects of physical and motor exercises [1,7] and those of video game training on cognitive performance Delaying or attenuating age-related cognitive decline is critical [8,9]. However, until now, no study has systematically for preserving autonomy and quality of life of the increasing compared, within the same experimental protocols, the number of older adults. It has been widely demonstrated that respective benefits of ‘conventional’ CTIs and exergames with separate cognitive, aerobic, muscular, and motor training are regard to cognitive outcomes in healthy older adults. “A review effective in this respect [1]. Moreover, it has been suggested of reviews” (ie, 3 reviews on conventional cognitive and motor that their integration into combined training interventions (CTIs) training and 3 on exergames) [10] recently addressed this issue might be more effective than separated training [2-4]. In this and reported conflicting results. Specifically, the benefits of context and in view of the role played by cognitive stimulations conventional CTIs were found superior to those of separated in CTIs [5,6], exergames (ie, interactive video games that require training in 2 reviews, but the superiority of exergames over participants to be physically active to play) might be even more https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 1 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre physical or cognitive training alone was unclear in the selected framework developed in 2 recently published review papers reviews. dedicated to conventional CTIs [11] and exergames [12], we compiled the data of 47 studies to compare randomized This paper aims to go a step further by reporting the results of controlled trials and controlled trials that have used either a detailed comparison of studies that used conventional CTIs conventional combined training or exergames to improve and those that used exergames to improve brain and cognition cognitive functions (Table 1 and Table 2). in healthy older adults. To fulfill this objective, based on the Table 1. Selected reviews and studies on conventional combined training interventions. Studies were classified as a function of the type of combined intervention. Conventional combined Studies training interventions Reviews Law et al [13], Wollesen and Voelcker-Rehage [14], Zhu et al [15], Lauenroth et al [3], Levin et al [16], Tait et al [17], Gheysen et al [2], Joubert and Chainay [18], Gavelin et al [19], Wollesen et al [20], Gallou et al [10], Gou et al [21] Studies Sequential Fabre et al [22], Legault et al [23] PCT Shatil et al [24], Linde and Alfermann [25], Shah et al [26], Mc Daniel et al [27], Desjardins-Crépeau et al [28] Oswald et al [29] MCT Pieramico et al [30], Van het Reve and de Bruin [31], Rahe et al [32], Rahe et al [33], Kalbe et al [34] MDT Simultaneous PCT Theill et al [35], Leon et al [36], Norouzi et al [37], Eggenberger et al [38], Eggenberger et al [39] MCT Hiyamizu et al [40], Marmeleira et al [41], Falbo et al [42] MDT Ansai et al [43], Yokoyama et al [44], Nishiguchi et al [45], Jardim et al [46] PCT: physical-cognitive training. MCT: motor-cognitive training. MDT: multidomain training. Table 2. Selected reviews and studies on exergames. Studies were classified as a function of the type of combined intervention. Exergames interventions Studies Reviews Zhang and Kaufman [47], Bleakley et al [48], Ogawa et al [49], Howes et al [50], Stanmore et al [51], Vázquez et al [52], Mansor et al [53], Stojan and Voelcker-Rehage [54], Gallou-Guyot et al [10], Wollesen et al [20], Gavelin et al [19], Sakaki et al [55], Soares et al [56] Studies Sequential a b PCT — Park and Yim [57] MCT Kayama et al [58] MDT Simultaneous PCT Anderson-Hanley et al [59], Barcelos et al [60] MCT Schoene et al [61], Schoene et al [62], Gschwind et al [63], Schättin et al [64], Adcock et al [65], Carrasco et al [66], Eggenberger et al [39], Eggenberger et al [67], Huang [68], Li et al [69] MDT Maillot et al [70], Chuang et al [71], Ordnung et al [72], Guimaraes et al [73], Htut et al [74], Bacha et al [75], Peng et al [76], Moreira et al [77], Gouveia et al [78] PCT: physical-cognitive training. Not available. MCT: motor-cognitive training. MDT: multidomain training. https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 2 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre Accordingly, 3 main training modes were distinguished: (1) A Structured Framework for Analyzing physical-cognitive training (PCT), which correspond to the Combined Training Interventions association of endurance (aerobic) and muscular resistance training and cognitive training, either sequentially or We developed a framework to analyze CTIs, independent of simultaneously; (2) motor-cognitive training (MCT), which whether they were delivered via conventional interventions or refers to the association of complex motor skills training and via exergames. Specifically, we distinguished the following: cognitive training, implemented through the addition of (1) the stimuli, which refer to different types of combined cognitive tasks separated from the motor tasks (eg, mental training; (2) the settings, which are the organizing features of calculation); and (3) multidomain training (MDT), which training programs (ie, frequency, duration, intensity, instructions, consists of associating aerobic exercises, complex motor skills, feedback, individualization, and progressivity of increase in and cognitive tasks through laboratory-customized training difficulty); (3) the targets of training, which were limited in this situations. Notably, for conventional CTIs, we limited our review to brain and cognitive levels, but other levels could be analysis to randomized controlled trials and controlled trials in added in future works; (4) the markers, that is, the tasks and which it was possible to identify different training components tests used to train or assess the participants, respectively; (5) (ie, physical, motor, and cognitive) that were associated with the outcomes of different types of training, that is, the different each other. Thus, according to this criterion, interventions variables that allow for quantifying the observed effects at brain implemented through natural motor activities (eg, tai chi, dance, and cognitive levels; (6) the moderators, who modulated the or Nordic walking) were excluded. Although these activities effects of training; and (7) the potential mechanisms, which included physical, motor, and cognitive components, their were explicitly mentioned in different studies to predict and respective weights and levels of intensity or complexity were explain the effects of combined training (Figure 1). difficult to quantify. Based on this framework, in this study, we focused our comparative analysis on the following 4 main constructs: stimuli, settings, targets, and outcomes. Figure 1. A multidimensional framework to analyze combined training interventions (detailed explanations are presented in a previous study [11]). Published under Creative Commons Attribution 4.0 International License. https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 3 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre whereas it was the case in only 1/23 (4.3%) of the exergames The Database studies. Most frequently, exergames studies included 2 groups, that is, either a passive control group (9/23, 39.1%), a physical Our analysis was grounded on the material included in 2 recently or motor training group (13/23, 56.5%), or less frequently, a published reviews dedicated to conventional CTIs [11] and cognitive training group (2/23, 8.6%), in addition to the exergames [12], respectively. Specifically, 24 studies on exergaming group. In both conventional CTI and exergames conventional training and 23 studies on exergames, published studies, permanence and transfer of training effects were from 2010 to November 2021, were selected on the basis of scarcely investigated, so no reliable conclusion can be drawn several criteria [11,12]. These studies were then analyzed to in this respect. compare them according to the 4 chosen constructs of our framework (Table 1 and Table 2). Targets No main difference was observed between the cognitive abilities Quantitative and Qualitative Differences tested in conventional CTIs and exergames studies. The most Between Conventional Interventions and frequently tested were memory, executive functions, attention, and information processing speed, but there were no ‘a priori’ Exergames assumptions about the type of functions that could be affected more or less by each CTI. The respective effects of conventional Stimuli combined training and exergames on brain health and Motor and cognitive exercises were performed simultaneously neurobiological mechanisms cannot be reliably compared due in 100% (n=23) of the exergames studies, whereas sequential to the small number of related studies and their heterogeneity presentation of physical and cognitive exercises was used in (ie, 4 and 2 studies, respectively). 58% (7/12) of conventional PCT studies, 22% (2/9) of MDT studies, and 50% (2/4) of MCT studies. Thus, one can Outcomes hypothesize that several studies on conventional CTIs used Combined Training Versus Passive Control Groups mechanisms that were different from those involved in exergame interventions. Another important issue concerns the distribution Independent of the training modes (ie, PCT, MCT, or MDT), of the 3 training modes (ie, PCT, MCT, and MDT), which positive effects were observed, relative to passive control differed in conventional CTI and exergames studies. Indeed, groups, in all conventional CTIs and exergames studies, for at the proportion of PCT studies was much higher for conventional least one of the targeted cognitive functions, that is, memory, interventions compared to exergaming (12/24, 50% and 2/23, attention, executive functions, and information processing speed. 8%, respectively), whereas the inverse was observed for MCT These results were observed for both sequential and 16% (4/24) for conventional interventions and 47% (11/23) for simultaneous associations between cognitive and physical or exergaming, respectively) and MDT studies 37% (9/24) for motor exercises. Unfortunately, it was impossible to determine conventional studies and 43% (10/23) for exergaming, whether cognitive functions were differently impacted by respectively). This resulted from the predominant use of conventional combined training and exergames, respectively. commercial exergames (eg, Xbox Kinect and Wii Balance These results are consistent with those reported by Gallou-Guyot Board), which were cheaper than the stationary cybercycle used et al [10]. Unsurprisingly, they suggest that regardless of how for implementing PCT in exergames studies [59,60]. It could combined training is delivered (ie, conventional interventions be concluded from the distribution of PCT in both conventional or exergames, and PCT, MCT, or MDT), combined training and exergaming intervention studies that, on average, the latter programs always lead to superior benefits compared to was less physically demanding than the former; supporting inactivity. evidence could be found in a study by Graves et al [79], and a Combined Training Versus Physical Training discussion is presented in Gonçalves et al’s 2021 study [80]. In conventional CTIs, superior benefits of combined training However, this issue is a matter of debate, since few studies over separated physical training were observed in 100% (n=13) demonstrated that commercial exergames can be the support of of MCT and MDT studies and in most of the PCT studies (8/12, intense physical activity [81,82], whereas others showed that 66.6%). On the other hand, superior benefits of exergaming they only facilitated light- to moderate-intensity physical activity compared to conventional physical or motor training alone were [83]. On the other hand, since commercial exergames usually observed in only one study on exergames [59], whereas no required upper limb movements, whole body movements, difference was found between the exergames and separated stepping, weight shifting or balance control, motor exercises training groups in the 4 other studies (2 on MCT and 2 on supporting MCT and MDT in conventional CTIs and exergames MDT). studies were roughly similar. Combined Training Versus Cognitive Training Settings In conventional training studies, compared to cognitive training Conventional CTIs most frequently aimed to compare several alone, superior benefits of CTIs were observed in almost groups simultaneously. Indeed, 21/24 (87%) involved a passive one-third of PCT studies (n=4), but never in MCT and MDT control group, alone or together with cognitive training (15/24, studies. In the 2 studies that compared exergaming and cognitive 62%) and physical or motor training (13/24, 54%) groups. In training, one reported a superiority of the former over the latter total, 8/24 (33%) of the conventional training studies involved on executive functions [67], whereas the other did not [74]. 3 training groups (ie, CTI, physical or motor, and cognitive), https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 4 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre Thus, the number of related studies was too small to draw exergames did not allow reaching high enough levels of physical reliable conclusions about the superiority of exergames over effort [10] or motor skills complexity, and they used the cognitive training alone. resources of virtual reality and video games insufficiently to improve the cognitive load of different exercises [84]. This is Limitations and Study Comparisons not to say that exergame interventions cannot succeed in being more effective than conventional CTIs. However, further studies, The studies including 4 training groups (ie, combined training, grounded on theoretical knowledge provided by the literature separated physical and cognitive training, and a control group), on physical, motor, and cognitive training are necessary to which could allow for a complete comparison, were scarce (ie, determine whether interventions delivered via exergames may 8 conventional training studies out of 47, in total). A second lead to superior benefits compared to separated and combined observation was that despite the type of intervention (ie, CTIs. In particular, since commercial exergames are not conventional or exergames), the mechanisms underlying designed specifically for older adults, exergames studies should eventual differences with physical and cognitive training groups use new solutions that are more grounded on theoretical were rarely addressed in the reviewed studies. A third foundations [84]. observation was that information relative to intensity and the Finally, this analysis showed that conventional CTIs and nature of physical exercises, the nature and levels of complexity exergames studies did not address the same research questions, of motor exercises, and progressivity of difficulty was neglected thereby precluding reliable comparisons of their benefits. in most studies, so it was impossible to estimate why physical Specifically, conventional CTI studies prominently aimed to or motor training was effective (or not) to improve physical, compare benefits of separate training programs, whereas motor, or cognitive performance. This was the case, in particular, exergames studies focused on the benefits of exergaming per in exergames studies. In addition, in several studies, cognitive se, most often relative to inactive control groups. Thus, training procedures and (exer)game contents were not described contrarily to our expectations, they seem to be separated or were only superficially described. Finally, due to the small domains of the literature on aging, which, until now, have number of studies available to support some comparisons (eg, developed independently of each other. In particular, the exergames and cognitive training; conventional CTI vs literature on exergames has not yet reached the level of maturity exergames), the results remain to be confirmed or even of those on conventional CTIs, which itself remains established in future studies. heterogeneous and suffers from methodological weakness and lack of a strong conceptual background [11,84,85]. Therefore, Discussion although they both allow for delivering combined training programs, conventional and exergames interventions are not In this paper, we aimed to determine whether conventional CTIs two facets of the same coin; rather, they are two coins we do and exergames were two comparable ways for delivering not know which is more valuable. Accordingly, future studies combined training. Our analysis showed that conventional CTIs should aim to develop new exergames that would capitalize were more effective than separated physical and motor training more on the knowledge from studies on conventional CTIs, to improve brain and cognition, but their superiority over particularly concerning the underlying mechanisms. These cognitive training alone remains to be confirmed in further studies should also systematically compare the effectiveness of studies. 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[doi: 10.1016/j.arr.2018.04.002] [Medline: 29679658] Abbreviations CTI: combined training intervention MCT: motor-cognitive training MDT: multidomain training https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 9 (page number not for citation purposes) XSL FO RenderX JMIR SERIOUS GAMES Temprado & Torre PCT: physical-cognitive training Edited by N Zary; submitted 22.03.22; peer-reviewed by M Gallou-Guyot; comments to author 21.07.22; revised version received 22.07.22; accepted 04.08.22; published 03.10.22 Please cite as: Temprado JJ, Torre MM Are Conventional Combined Training Interventions and Exergames Two Facets of the Same Coin to Improve Brain and Cognition in Healthy Older Adults? Data-Based Viewpoint JMIR Serious Games 2022;10(4):e38192 URL: https://games.jmir.org/2022/4/e38192 doi: 10.2196/38192 PMID: ©Jean-Jacques Temprado, Marta Maria Torre. Originally published in JMIR Serious Games (https://games.jmir.org), 03.10.2022. This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Serious Games, is properly cited. The complete bibliographic information, a link to the original publication on https://games.jmir.org, as well as this copyright and license information must be included. https://games.jmir.org/2022/4/e38192 JMIR Serious Games 2022 | vol. 10 | iss. 4 | e38192 | p. 10 (page number not for citation purposes) XSL FO RenderX

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JMIR Serious Games – JMIR Publications

Published: Oct 3, 2022

Keywords: aging; older; gerontology; exergame; physical activity; cognition; training; intervention; cognitive; brain; older adult; motor skills; exercise; physical; motor; combined training

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