Abstract
Background
Given the increasing prevalence of Mild Cognitive Impairment (MCI) among the elderly as a precursor to dementia, understanding how targeted interventions can improve daily functioning and delay cognitive decline is critical to improving quality of life in aging populations.
Objective
To investigate the effects of hand exercises and cognitive training on cognitive functions, hand skills, grip strength, dual-task-performance and interactions in elderly individuals with MCI.
Materials and methods
A randomized, single-blind study was conducted with 47 participants aged 65 and older living in nursing homes. Participants were divided into hand exercise group (HEG = 15), cognitive exercise group (CEG = 15) and control group (CG = 17). Exercise was applied to HEG and CEG for 8 weeks. Cognitive functions, grip strength, hand skills, motor-motor dual task performance (MMDTP), motor-cognitive dual task performance (MCDTP), motor-motor dual task interaction (MMDTI), motor-cognitive dual task interaction(MCDTI) and Manual Ability Measurement (MAM-36) were assessed.
Results
HEG improved in hand skills, grip strength, MCDTP, MMDTP, and MAM-36, with reduced MCDTI. CEG showed gains in cognition, MMDTP, and hand use (p < 0.05).
Conclusions
Hand exercises enhance motor and functional ability, while cognitive exercises supports cognitive performance and MMDTP.
Trial registration
The clinical protocol of the study was registered in the ClinicalTrials.gov system, registration number: NCT06837493.
Keywords: Mild cognitive impairment, Hand exercises, Cognitive training, Hand functions, Cognitive functions, Elderly individuals
Introduction
Due to the natural physiological processes of aging, structural deteriorations in the cognitive areas of elderly individuals, and cognitive abilities decrease [1, 2]. This situation can negatively affect the daily lives of elderly individuals and lead to serious cognitive problems [3, 4]. Among these neurocognitive diseases, the most common in the elderly are Mild Cognitive Impairment (MCI) and Alzheimer’s disease (AD) [1, 5, 6].
The global prevalence of MCI has been reported to exceed 15% among community-dwelling adults aged 65 years and older [1]. Such high rates reveal that the cognitive health of the elderly is at serious risk. In addition to the decreased cognitive functions seen in MCI, neuropsychological symptoms also accompany [7]. Studies have shown that 8–15% of elderly individuals with MCI progress to more severe forms of dementia such as AD within a year [2, 6]. Previous studies have pointed out that cognitive impairment does not directly cause the deterioration in hand motor functions, but rather that there is a strong relationship between the two [8, 9].
The reason for this is based on the interaction between the relevant neuronal connections that provide the motor functions of the hand and the cortical areas of the brain [10]. It is a matter of curiosity how a degenerative change that may occur in this interaction will be reflected in elderly individuals. The question of whether cognitive functions affect manual dexterity has been addressed extensively in the literature, and the available evidence largely supports the existence of this relationship [11, 12]. However, the answer to the question of whether the deterioration of the motor functions of the hand affects cognitive function has not been clearly found in the literature. Age-related neurocognitive decline commonly manifests as MCI and may progress to Alzheimer’s disease. Beyond cognitive symptoms, hand motor functions have been shown in many different studies to play a critical role in maintaining independence in activities of daily living [10, 13]. It has also been emphasized that hand motor functions share common cortical networks with executive functions [11, 14]. Accordingly, this randomized, assessor-blinded controlled trial aimed to compare a pragmatic hand-focused program with a cognitive-focused program in older adults with MCI, evaluating effects on functional manual ability, manual dexterity, grip strength, global cognition, and dual-task performance/interaction; we hypothesized that the hand-focused program would preferentially enhance manual outcomes, whereas the cognitive-focused program would yield larger gains in cognitive and dual-task measures.
Materials and methods
Study design
The study was planned as a parallel, single-blind, randomized controlled, experimental study design. This study was reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 2025 guideline [15].
Participants and setting
The universe of the study consisted of elderly individuals with MCI. The sample of the study consisted of 47 elderly individuals with MCI living in four different Elderly Care and Nursing Homes located in the Central Region of Yozgat in Turkey and meeting the inclusion criteria of the study. The sample size of the study was calculated after the data collection stage with a 95% confidence interval using the “G. Power-3.1.9.2” program. Accordingly, the F test values performed on three group comparisons in the study were examined. According to the power analysis performed on the groups with different F test values in the second measurement, the power of the study was found to be 92% with 47 cases. The inclusion criteria for the study were: being 65 years of age or older, volunteering for training, receiving 16–20 points from the Montreal Cognitive Assessment Scale (MoCA), and being at least literate. Exclusion criteria for the study were determined as follows: Individuals with a diagnosis of dementia and other neurological conditions (e.g., stroke, Parkinson’s disease, multiple sclerosis, epilepsy, etc.) were excluded from the study. Additionally, participants with a history of psychiatric conditions that could be clinically confused with MCI (especially major depression and anxiety disorder) were also excluded from the study population before evaluation. Having serious auditory and visual problems, having unstable chronic disease (acute myocardial infarction, respiratory distress advanced enough to require oxygen supplementation), having had a history of major surgery in the last six months, upper extremity disorders (serious shoulder, elbow, wrist, finger or bilateral elbow, hand-wrist fractures or advanced rheumatoid arthritis). Participants included in the study were asked to sign an informed consent form and were informed about the study. The MCI determination was made by an independent expert physiotherapist reviewing institutional records. The Mini Mental State Examination (MMSE) was not administered by the research team; previous assessments found in the institution’s medical records were used. Participants with an MMSE ≥ 24 were included in the study. Subsequently, the Turkish MoCA was administered by the research team, and individuals with a MoCA score < 21 were classified as MCI. According to the Turkish validity and reliability study of MoCA, scores below 21 points are evaluated as indicative of MCI [16]. The definition of MCI was based on cognitive test performance, and the level of functional independence in activities of daily living was not directly assessed; this should be considered a methodological limitation in defining the study population.
Ethics statement
The study received ethical permission from Mugla Sıtkı Kocman University Medical and Health Sciences Ethics Committee-2 dated 22/12/2021 with the decision number 36. In order to reach the sample group specified in the study, a work permit numbered E-84459573-605.01[605.01]-2,751,539 dated 24/02/2022 was obtained from the Ministry of Family and Social Policies of Turkey. The study was conducted in accordance with the Helsinki Declaration. All participants were informed about the study and their written consent was obtained. This study was registered at https://clinicaltrials.gov/ Clinical trial ID: NCT06837493.
Data collection tools
Sociodemographic Data Form: This is a structured data form prepared by the researcher that includes participants’ age, gender, education level, chronic disease history, and hand dominance information.
Montreal Cognitive Assessment Scale (MoCA): MoCA is a 30-point semi-structured screening test developed to assess global cognitive functions. It assesses cognitive domains such as attention, memory, executive functions, language, visuospatial skills, and orientation. Although this test includes executive functions, it should be noted that executive functions are only a subcomponent of the MoCA, and the MoCA is not used directly as a test of executive function. The original form of the scale was developed by Nasreddine et al. in 2005 [17]. The Turkish form, which has been validated and proven to be reliable, was used [16]. Since the assessments were administered at approximately eight-week intervals, the possibility of test-retest recall cannot be completely excluded; however, the administrations were conducted under the same environment and standardized conditions.
Edinburgh Handedness Inventory (EHI): This is a self-reported, 10-item questionnaire used to determine hand dominance. The original version of this questionnaire was developed by Oldfield in 1971, and the Turkish version was adapted by Atasavun et al., (2019), and its reliability and validity study was conducted [18, 19]. The results are scaled to determine right-, left-, or ambidextrous hand preference.
Nine-Hole Peg Test (NHPT): This is a performance-based, standardized test that assesses manual dexterity and fine motor hand coordination. The participant is asked to place and remove nine pegs into holes as quickly as possible. A shorter time indicates better dexterity.
Takei Digital Hand Dynamometer (THD-5401): This is a digital dynamometer that objectively measures handgrip strength in kilograms. During measurement, the participant is asked to perform a maximal isometric contraction.
Motor-Motor and Motor-Cognitive Dual-Task Performance: Motor-Motor (MMDTP) and motor-cognitive (MCDTP) dual-task performances were measured using a stopwatch. Motor-motor dual-task performance (MMDTP) was assessed by having participants perform a manual dexterity task (NHPT) simultaneously with another motor task (rhythmically tapping the fingers). Motor-cognitive dual-task performance (MCDTP) was measured by having participants perform a cognitive task (counting backwards the days of the week) simultaneously during the same manual task. In both dual-task performances, the duration of the task was recorded in seconds with a stopwatch. These tests were adapted from hand-based dual-task studies in the literature [20] and standardized by the research team within the scope of the study.
Manual Ability Measure-36 (MAM-36):This is a self-reported 36-item questionnaire that assesses manual dexterity and manual functions related to upper extremity use in activities of daily living. A higher score represents better functional performance. The original version of the scale was developed by Chen and Bode (2010) [21]. The validity and reliability study of the Turkish version was conducted by Cinbaz (2017) [22].
Dual Task Interaction (DTI): DTI was calculated to quantitatively assess performance changes across tasks using the formula DTI = (Single Task Performance – Dual Task Performance) / Single Task Performance x 100 [23].
In the NHPT, MMDTP, and MCDTP tests, it has been accepted that performance improves with decreasing time, meaning that shorter time indicates better manual dexterity and dual-task performance. In the THD (hand dynamometer) test, a higher score indicates increased handgrip strength. A higher score on the MAM-36 scale indicates that the individual uses their hand more functionally and effectively in activities of daily living. A higher score on the MoCA scale indicates improved cognitive function. For the DTI, positive values indicate increased performance during dual-tasking compared to single-tasking (dual-task ease), while negative values indicate a loss of performance during dual-tasking (dual-task cost).
Data collection process
The study was conducted in four different elderly care and nursing homes located in Central Region of Turkey between February 2022-February 2023. While collecting data from the participants, both pre-intervention and post-intervention evaluations were made. The evaluations were made by another expert physiotherapist other than the researcher physiotherapist. 165 participants were evaluated. 114 did not meet the criteria. However, 51 participants were included in the study. A total of 51 participants were included in the study and were randomly assigned to three groups of 17 participants each. The groups were named as HEG, CEG and CG. HEG: Hand exercises group, CEG: Cognitive exercise group, CG: Control group. A total of four participants withdrew from the study during the study period—two from HEG and two from CEG. No CG participants withdrew. In accordance with safety guidelines, participants were instructed to immediately discontinue exercise if they experienced symptoms such as shortness of breath, heart problems, intolerance, or excessive fatigue. Accordingly, the study was completed with a total of 47 participants. Figure 1 shows the participant flow chart organized according to the CONSORT 2025 guideline.
Fig. 1.
Patient flowchart according to the CONSORT 2025 guidelines
Randomization
Participants were assigned to three groups using the block randomization method. The randomization process was performed by an expert biostatistician using computer-aided random number generation. This method aimed to balance potential confounding factors at baseline between the groups.
Bias
In the study process, in the planning of each stage of the study, before, during and after data collection, it is necessary to prevent bias in terms of scientific generalizability and acceptance of the results [24]. For this purpose, literature was scanned from current, sufficient and reliable references on the subject before the data of the study was collected. In order to ensure evaluator blindness in the study, the participants were evaluated by another expert physiotherapist other than the researcher. The evaluations were made twice, before and after the intervention. The data were also checked by the statistician during the statistical analysis process. Thus, an accurate and reliable objective statistical analysis was performed.
Intervention
The pre- and post-training evaluations of the subjects participating in the study were performed by an expert physiotherapist other than the researchers. All intervention sessions were implemented one-to-one in a special physiotherapy exercise room within the rehabilitation unit of the nursing home, accompanied by a research physiotherapist.
Hand exercise group (HEG — 3 sessions/week × 8 weeks) each session ≈ 30 min, 3 times per week, 8 weeks total
Resisted hand exercises + functional task-focused hand activities.Sessions were conducted using materials such as putty, hand springs, hand exercise balls, water bottle transfers, and bead stringing. Structured based on the Oxford Hand Therapy Protocol and Schaefer et al., 2015 and [25].
Cognitive exercise group (CEG — 3 sessions/week × 8 weeks)
Each session ≈ 30 min, 3 times per week, 8 weeks total.
Neurological rehabilitation protocols focused on attention, memory, visual-spatial perception, and executive function were implemented. Activities included story repetition, puzzles, serial subtraction, shape completion, and visual memory exercises. The program was adapted based on neurologist consultation and Torpil (2020) and cognitive rehabilitation studies in the literature [26].
Control group (CG)
No intervention was implemented during the CG study, and the participants’ routine daily living activities and existing care processes were not interrupted. Only a pre-post assessment was performed. However, after the study was completed, participants in the control group received delayed intervention support by providing informative exercise materials and educational brochures. This practice was implemented in accordance with the principle of non-withdrawal of the intervention and ethical fairness.
Adverse events
No serious or non-serious adverse events attributable to the interventions were observed in any group (HEG, CEG, CG).
Statistical analysis
The obtained data were analyzed using the Statistical Package for Social Sciences for Windows 25.0 program. Descriptive statistics (mean ± SD/median [IQR]) were reported. Normality of measurements was assessed using skewness-kurtosis values, histograms, and Q-Q plots. To evaluate pre-post changes within groups, paired t-tests were used for parametric cases, and Wilcoxon test was used for non-parametric cases. For inter-group comparisons, one-way ANOVA was used for parametric cases, Kruskal–Wallis test for non-parametric cases, and Bonferroni post-hoc test was used for significance.Because no statistically significant difference was found between the groups in the initial (pre-test) values, intergroup comparisons were made only on the post-intervention (post-test) values. Therefore, within-group changes were assessed using pre-test-post-test analyses, and between-group differences were interpreted based on the post-test results. Additionally, post-post change scores were compared descriptively to assess trends in change between groups. A two-sided significance level of α = 0.05 was accepted for all tests.
Results
The mean age of the 47 participants participating in the study was found to be 76.45 ± 6.95 (minimum: 65, maximum: 89). Their mean BMI values were as 27.14 ± 2.07 kg/m2. It was determined that CEG, HEG and CG were similar in terms of physical characteristics (p > 0.05). When the gender distribution of the participants participating in the study was examined according to their sociodemographic characteristics, 63.8% (n = 30) were female and 36.2% (n = 17) were male. It was determined that 100% of the participants were single. It was determined that 57.4% of the participants were literate, 31.9% primary school, 4.25% secondary school, and 6.38% high school. It was observed that CEG, HEG and CG were similar in terms of sociodemographic characteristics (p > 0.05)(Table 1). All participants had chronic diseases and were taking medication. Exercise habits, use of ambulatory assistive devices and hand preferences showed a similar distribution between the groups (p > 0.05)(Table 1).
Table 1.
Sociodemographic, physical and clinical characteristics of the participants
| Variable | HEG (n,%) | CEG (n,%) | CG (n,%) | Total (n,%) | Test statistic | p-value |
|---|---|---|---|---|---|---|
| Gender (female) | 7 (46.7%) | 5 (33.3%) | 5 (29.4%) | 30 (63.8%) | 1.104 | 0.576 |
| Gender (male) | 8 (53.3%) | 10 (66.7%) | 12 (70.6%) | 17 (36.2%) | 1.104 | 0.576 |
| Education (literate) | 7 (46.7%) | 10 (66.7%) | 10 (58.8%) | 27 (57.4%) | 3.397 | 0.527 |
| Education (primary) | 5 (33.3%) | 5 (33.3%) | 5 (29.4%) | 15 (31.9%) | 3.397 | 0.527 |
| Education (secondary) | 1 (6.7%) | 0 (0.0%) | 1 (5.9%) | 2 (4.3%) | 3.397 | 0.527 |
| Education (high) | 2 (13.3%) | 0 (0.0%) | 1 (5.9%) | 3 (6.4%) | 3.397 | 0.527 |
| Exercise habit (yes) | 1 (6.7%) | 0 (0.0%) | 2 (11.8%) | 3 (6.3%) | 1.953 | 0.638 |
| Exercise habit (none) | 14 (93.3%) | 15 (100%) | 15 (88.2%) | 44 (93.7%) | 1.953 | 0.638 |
| Ambulatory device (none) | 10 (66.7%) | 10 (66.7%) | 8 (47.1%) | 28 (59.6%) | 2.854 | 0.885 |
| Ambulatory device (cane) | 3 (20.0%) | 2 (13.3%) | 4 (23.5%) | 9 (19.1%) | 2.854 | 0.885 |
| Ambulatory device (walker) | 1 (6.7%) | 1 (6.7%) | 3 (17.6%) | 5 (10.6%) | 2.854 | 0.885 |
| Ambulatory device (wheelcair) | 1 (6.7%) | 2 (13.3%) | 2 (11.8%) | 5 (10.6%) | 2.854 | 0.885 |
| Handedness(right) | 12 (80.0%) | 11 (73.3%) | 15 (88.2%) | 38 (80.9%) | 1.153 | 0.562 |
| Handedness(left) | 3 (20.0%) | 4 (26.7%) | 2 (11.8%) | 9 (19.1%) | 1.153 | 0.562 |
| Variable | HEG (1) X ± SD | CEG (2) X ± SD | CG (3) X ± SD | Total X ± SD | KW | p |
| Age (years) | 75.73 ± 6.67 | 74.00 ± 6.92 | 79.24 ± 6.61 | 76.45 ± 6.95 | 4.408 | 0.110 |
| Height (m) | 1.70 ± 0.09 | 1.70 ± 0.08 | 1.71 ± 0.08 | 1.71 ± 0.08 | 0.296 | 0.862 |
| Weight (kg) | 78.27 ± 12.55 | 80.20 ± 11.02 | 79.35 ± 9.92 | 79.28 ± 10.94 | 0.406 | 0.816 |
| BMI (kg/m2) | 26.79 ± 2.28 | 27.67 ± 1.84 | 26.98 ± 2.10 | 27.14 ± 2.07 | 1.414 | 0.493 |
HEG Hand Exercise Group, CEG Cognitive Exercise Group, CG Control Group, m meter, kg kilogram, BMI Body Mass Index, n Number of participants, X mean, SD Standart Deviation, KW Kruskal Wallis H test,
*p < 0.05
The left and right side NHPT scores in HEG showed a significant decrease after the training (p < 0.05). No significant difference was found in the CEG and CG. In group comparisons, the NHPT scores of CEG were found to be significantly higher than CG and HEG (p < 0.05) (Table 2). This decrease suggests that participants improved their dexterity and fine motor control.
Table 2.
Comparison tests of NHPT according to groups and time
| Variable | HEG (1) X ± SD | CEG (2) X ± SD | CG (3) X ± SD | Test statistic | p-value | Bonferroni Post Hoc |
|---|---|---|---|---|---|---|
| NHPT left1 | 29.34 ± 5.36 | 37.76 ± 16.06 | 28.36 ± 4.47 | 6.137 F | 0.047* | 2 > 3 |
| NHPT left2 | 25.94 ± 4.62 | 36.37 ± 13.83 | 28.06 ± 4.19 | 11.045 KW | 0.004* | 2 > 1 |
| NHPT right1 | 28.66 ± 4.13 | 34.71 ± 9.76 | 27.55 ± 3.34 | 7.011 KW | 0.030* | 2 > 3 |
| NHPT right2 | 24.79 ± 3.63 | 33.80 ± 10.35 | 27.16 ± 3.12 | 10.221 KW | 0.006* | 2 > 1 |
X Mean, SD Standart Deviation, z Wilcoxon sign test, F one-way analysis of variance, KW Kruskal Wallis H test, 1: pre-intervention, 2:post-intervention
*p < 0.05
Grip strength, THD scores (left and right hand) in HEG showed a significant increase after training (p < 0.05). No significant change was observed in CEG and CG. In the differences between the groups, HEG and CEG scores were significantly lower than CG (p < 0.05)(Table 3). This increase indicates a significant increase in participants’ hand muscle strength and improved muscle endurance.
Table 3.
Comparison tests of the THD test according to groups and time
| Variable | HEG (1) X ± SD | CEG (2) X ± SD | CG (3) X ± SD | Test statistic | p-value | Bonferroni Post Hoc |
|---|---|---|---|---|---|---|
| THDleft1 | 15.91 ± 5.99 | 18.35 ± 5.88 | 25.56 ± 6.77 | 10.440 F | 0.000* | 1,2 < 3 |
| THDleft2 | 20.08 ± 5.69 | 18.18 ± 5.40 | 25.71 ± 6.53 | 7.069 F | 0.002* | 1,2 < 3 |
| THDright1 | 17.32 ± 7.23 | 20.37 ± 6.71 | 27.28 ± 6.66 | 8.932 F | 0.001* | 1,2 < 3 |
| THDright2 | 21.17 ± 6.21 | 20.78 ± 6.38 | 26.45 ± 6.74 | 3.907 F | 0.027* | 2 < 3 |
THD Takei Hand Dynamometer, X Mean, SD Standart Deviation, z Wilcoxon sign test, F one-way analysis of variance, KW Kruskal Wallis H test, 1: pre-intervention, 2:post-intervention
*p < 0.05
In HEG, MMDTP scores showed a significant decrease for the left and right sides after training (p < 0.05). An increase was observed on the left side in CEG, but no significant change occurred on the right side. No difference was found in CG. In the comparisons between the groups, the scores of the CEG and CG were found to be significantly higher compared to HEG (p < 0.05) (Table 4). The decrease in duration indicates that individuals can perform two motor tasks simultaneously more quickly and in a more coordinated manner, meaning that efficiency in motor skills increases. A significant decrease was observed in MCDTP scores in HEG after training (p < 0.05). No significant difference was found in the CEG. However, the scores showed a significant increase in CG (p < 0.05). In the differences between the groups, the scores of CEG were statistically significantly higher than those of HEG and CG (Table 4).
Table 4.
Comparison tests of the MMDTP, MMDTP, MMDTI and MCDTI tests according to groups and time
| Variable | HEG (1) X ± SD | CEG (2) X ± SD | CG (3) X ± SD | Test statistic | p-value | Bonferroni Post Hoc |
|---|---|---|---|---|---|---|
| MMDTP left1 | 32.91 ± 6.36 | 49.08 ± 21.28 | 36.71 ± 6.18 | 9.105 KW | 0.011* | 2 > 1 |
| MMDTP left2 | 29.67 ± 6.40 | 45.88 ± 21.14 | 36.70 ± 7.20 | 9.808 KW | 0.007* | 1 < 2,3 |
| MMDTPright1 | 31.92 ± 7.16 | 44.59 ± 13.76 | 35.57 ± 5.59 | 9.310 KW | 0.010* | 2 > 1 |
| MMDTPright2 | 28.01 ± 5.31 | 42.99 ± 13.92 | 35.56 ± 6.42 | 15.634 KW | 0.000* | 1 < 2,3 |
| MCDTP left1 | 43.56 ± 13.97 | 61.32 ± 22.60 | 36.60 ± 7.23 | 15.245 KW | 0.000* | 2 > 1,3 |
| MCDTP left2 | 41.79 ± 14.62 | 59.71 ± 20.16 | 39.09 ± 9.43 | 12.202 KW | 0.002* | 2 > 1,3 |
| MCDTP right1 | 44.07 ± 13.98 | 55.98 ± 18.61 | 36.22 ± 6.89 | 13.217 KW | 0.001* | 2 > 1,3 |
| MCDTP right2 | 42.30 ± 14.23 | 55.88 ± 18.50 | 38.58 ± 8.37 | 6.500 F | 0.003* | 2 < 1,3 |
| MMDTI left1 | –12.98 ± 15.09 | –31.49 ± 28.55 | –30.50 ± 13.07 | 11.008 KW | 0.004* | 1 > 3 |
| MMDTI left2 | -14.78 ± 16.71 | –25.44 ± 26.75 | –30.72 ± 15.60 | 2.560 F | 0.089 | – |
| MMDTIright1 | –11.03 ± 17.57 | –29.04 ± 23.00 | –29.16 ± 12.90 | 5.102 F | 0.010* | 1 > 2,3 |
| MMDTIright2 | –12.67 ± 11.43 | –29.56 ± 28.79 | –30.57 ± 16.06 | 3.896 F | 0.028* | 1 > 3 |
| MCDTI left1 | –47.32 ± 38.91 | –68.47 ± 42.05 | –29.11 ± 14.51 | 9.747 KW | 0.008* | 2 < 3 |
| MCDTI left2 | –55.49 ± 39.97 | –69.00 ± 37.18 | –38.90 ± 23.11 | 6.534 KW | 0.038* | 2 < 3 |
| MCDTI right1 | –48.80 ± 44.19 | –63.32 ± 45.40 | –31.48 ± 17.43 | 7.126 KW | 0.028* | 2 < 3 |
| MCDTI right2 | –70.95 ± 55.48 | –67.64 ± 43.62 | –41.96 ± 25.02 | 4.830 KW | 0.089 | – |
t dependent sample t test, z Wilcoxon sign test, F one-way analysis of variance, KW Kruskal Wallis H test, 1: pre-intervention, 2:post-intervention
*p < 0.05
No significant change was observed in MMDTI scores within the groups. However, group comparisons revealed that the HEG performed significantly better than CEG and CG (p < 0.05). The right side MCDTI scores in the HEG decreased significantly after training (p < 0.05). A significant decrease was observed on the left and right sides in CG. No significant change was observed in CEG. In the differences between the groups, CEG scores were significantly lower compared to CG (p < 0.05)(Table 4). The right side MCDTI scores in the HEG decreased significantly after training (p < 0.05).
A significant increase was found in the MAM-36 scores after the training in all groups (p < 0.05). The scores of the HEG were significantly lower compared to the differences before the training (Table 5). This increase shows that participants can use their hands more effectively, functionally and independently in daily living activities.
Table 5.
Comparison tests of MAM-36 and MoCA scores according to groups and time
| Variable | HEG (1) X ± SD | CEG (2) X ± SD | CG (3) X ± SD | Test statistic | p-value | Bonferroni Post Hoc | |||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| MAM-36 1 | 131.73 ± 6.04 | 138.80 ± 3.86 | 137.06 ± 6.75 | 6.219 F | 0.004* | 1 < 2,3 | |||||
| MAM-36 2 | 139.40 ± 4.82 | 139.93 ± 3.41 | 137.88 ± 6.58 | 0.684 F | 0.510 | – | |||||
| MoCA 1 | 17.47±1.55 | 18.00±1.73 | 17.18±1.38 | 1.139 F | 0.329 | ||||||
| MoCA 2 | 17.53±1.55 | 18.40±1.72 | 17.18±1.38 | 2.580 F | 0.087 | ||||||
t dependent sample t test, F one-way analysis of variance, 1: pre-intervention, 2:post-intervention
*p<0.05
A significant increase was observed in the MoCA scores in CEG after the training (p < 0.05). This increase indicates an improvement in the participants’ general cognitive functions. No significant difference was found in the other groups. No significant difference was found between the groups before and after the training period (p > 0.05)(Table 5).
Discussion
This study comparatively examined the effects of hand exercises and cognitive exercises on hand functions, grip strength, dual-task performance, and cognitive functions in elderly individuals with MCI. The findings demonstrated that both intervention approaches can produce positive results through different mechanisms. Significant increases in hand dexterity, grip strength, and hand use in daily life were observed in the HEG, while improvements in cognitive functions and left-hand dual-task performance were observed in the CEG. These results support the bidirectional interaction between motor and cognitive domains in elderly individuals.
Neurodegenerative changes that occur in both motor and cognitive domains with aging are a significant factor that threatens independence in activities of daily living. Previous research has emphasized the importance of manual dexterity for maintaining functional independence in older adults [10, 11]. It is suggested that hand function exercises stimulate not only muscle strength but also executive functions. This study supports this view, suggesting that improving hand dexterity may facilitate more efficient coordination of motor and cognitive processes required during dual-tasking. Similarly, Liu et al. (2018) reported that 12 weeks of passive finger exercises in individuals with dementia led to significant improvements in activities of daily living [27]. The improvements observed in the current study suggest that such exercises may promote plasticity between cognitive and motor networks.
The findings regarding the effects of cognitive exercises are also consistent with previous research. A small but significant increase in MoCA scores was observed on the CEG. Several meta-analysis studies demonstrated that cognitive rehabilitation had moderately positive effects on executive functions, memory, and attention in older adults with MCI [28–30]. Similarly, Gavelin et al. (2021) reported that 6–12-week cognitive training programs provided short-term improvements in cognitive performance, but these effects diminished in the long term [31]. These findings suggest that the eight-week intervention in the current study may have increased cognitive activation through short-term stimulation. These results indicate that the hypotheses initially identified in the study were largely confirmed; the hand-focused exercise program improved manual dexterity, grip strength, and motor-based dual-task performance as expected, while the cognitive exercise program provided significant improvements in cognitive functions and specific dual-task outcomes. Therefore, the findings meet the main aim of the study to examine the interaction between cognitive processes and hand functions in elderly individuals and reveal that two different intervention approaches contribute to functionality through different mechanisms.
Dual-task performance is a complex skill that requires the simultaneous execution of both motor and cognitive processes and is often significantly impaired in older individuals.
In the current study, a significant decrease in motor-motor and motor-cognitive dual-task times was observed in the hand exercise group. This result suggests that dual-task performance became more efficient and attentional resources were used more effectively.
A study by Kuo et al. (2022) reported that 8 weeks of dual-task-based training in older individuals with MCI resulted in significant improvements in gait and cognitive tasks [32]. Furthermore, several meta-analysises revealed that combined cognitive-motor interventions produced stronger effects compared to single-domain interventions. These results are consistent with the findings in the current study [33–35].
Law et al. (2022) reported that functional task-based exercises increased problem-solving and independence in older individuals [36]. These results suggest that both motor and cognitive stimulation indirectly improve functional independence. Indeed, meta-analytic findings support the moderate positive effects of both cognitive and physical exercises on quality of life and daily functioning in individuals with MCI [37].
From a clinical perspective, these findings highlight the importance of integrating both manual and cognitive exercises into physical therapy programs for older adults with mild cognitive impairment (MCI). These task-based and cost-effective approaches can increase functional independence and support the long-term preservation of cognitive engagement in older adults.
Limitations of the study
There are different subtypes of MCI in the clinic. The current MCI status of the elderly individuals participating in this study could not be evaluated together with the types of MCI. The study group consisted of fragile, weak and sensitive elderly individuals. Since the cases in this study group were composed of elderly people in nursing homes and nursing homes, the results of the study may be affected by different reasons such as the current physical, psychosocial conditions of the elderly and environmental factors. Although there were small baseline differences between the groups before the intervention, the interpretation of the results was based primarily on pre-post trend changes within the groups rather than absolute final measurement values. This approach is considered methodologically appropriate for randomized controlled trials conducted in heterogeneous elderly populations. Another limitation of the study is that the same version of the MoCA test used in the cognitive assessments was administered at pretest and posttest. This may have created a slight “practice effect” as participants became familiar with the test questions. Furthermore, the eight-week interval between assessments can be considered a relatively short timeframe for detecting true cognitive change. Therefore, increases in MoCA scores may not fully reflect true improvements in cognitive function, but this finding is still clinically valuable as it demonstrates the potential impact of short-term cognitive stimulation.
Conclusion
This study comparatively examined the differential effects of hand exercises and cognitive exercises in elderly individuals with mild cognitive impairment (MCI).The findings showed that hand exercises provided significant improvements in motor skills, grip strength, hand use, and dual-task performance, while cognitive exercises produced limited but significant improvements in attention and executive functions. These findings demonstrate that physical and cognitive domains support each other but act through different neural mechanisms.
From a clinical perspective, hand exercises can support independence in activities of daily living by strengthening not only peripheral muscle strength but also sensorimotor integration.
Cognitive exercises, on the other hand, are thought to play a complementary role in preserving higher-level cognitive functions by activating attention, problem-solving, and executive control processes. Therefore, it is recommended that rehabilitation programs for elderly individuals with MCI include both physical and cognitive components, structuring the exercises in a functional, task-based, and cognitively stimulating manner.
These results offer important clinical implications for physiotherapists and rehabilitation specialists. Low-cost, feasible, and accessible hand exercises and simple cognitive activities can be safely implemented in both institutional care settings and home programs.Such holistic approaches may contribute to slowing cognitive decline, increasing daily life independence, and maintaining quality of life in older individuals. However, given the short intervention period, small sample size, and lack of long-term follow-up, generalizations of the findings should be cautious. Future long-term studies with larger samples are important to confirm the clinical effectiveness and sustainability of these results.
Acknowledgements
We extend our gratitude to the expert physiotherapist Güldem Bozkurt for conducting the evaluations for this study.
Additional information
This article was derived from a doctoral thesis registered in the Turkish Council of Higher Education (YÖK) National Thesis Center (No: 842626). Publication permission was granted by the Ministry of Family and Social Policies of Türkiye (E-84459573-605.01-13485560; November 1, 2024).
AI disclosure
No generative artificial intelligence tools were used in the preparation of this manuscript.
Abbreviations
- EHI
Edinburgh Handedness Inventory
- NHPT
Nine Hole Peg Test
- THD
Takei Hand Dynamometer
- MMDTP
Motor-Motor Dual Task Performance
- MCDTP
Motor-Cognitive Dual Task Performance
- MAM
Manual Ability Measurement
- MCI
Mild Cognitive Impairment
- HEG
Hand Exercises Group
- CEG
Cognitive Exercise Group
- CG
Control Group
- DTP
Dual Task Performance
- DTI
Dual Task Interaction
Authors’ contributions
First Author: Conceptualization, Methodology, Investigation, Writing – original draft preparation, Supervision, Project administration.Second Author: Data curation, Formal analysis, Visualization, Writing – review & editing.
Funding
No financial support was received from any institution or organization for this study.
Data availability
Data are not publicly available due to participant confidentiality but may be shared upon reasonable request to the corresponding author.
Declarations
Ethics approval and consent to participate
The study received ethical permission from Mugla Sıtkı Koçman University Medical and Health Sciences Ethics Committee-2 dated 22/12/2021 with the decision number 36. In order to reach the sample group specified in the study, a work permit numbered E-84459573-605.01[605.01]-2751539 dated 24/02/2022 was obtained from the Ministry of Family and Social Policies of Turkey. The study was conducted in accordance with the Helsinki Declaration. All participants were informed about the study and their written consent was obtained.
Consent for publication
Not Applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data are not publicly available due to participant confidentiality but may be shared upon reasonable request to the corresponding author.