Motor–Cognitive Associations in Older Adults: A Cross-Sectional Study Toward Self-Assessment Tools

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Self-Diagnosis of Aging Profile according to Motor and Cognitive Functions: A Systemic Approach to Diagnosis and Intervention

 

This study seeks to examine how motor coordination skills relate to cognitive abilities in older adults, with the goal of developing a self-diagnostic model that will help identify and address cognitive decline early.

 

1.Introduction

Quite long.

Emphasize the need for making this study and the aim. The aim also needs to clearly define the population under study

 

2. Methods

Explicitly state study design, sampling procedure.

Provide detailed description of data gathering. When, where, how long…

Many paragraphs belong in introduction or discussion sections

 

3. Results

Check table 3 description carefully (page 8) - M and SD are mixed between SE and SEE

 Also check for unitary reporting measurements -  you report ms instead of seconds

It is difficult to distinguish core findings from secondary or contextual information.

Three were considered outliers (two males, one female) based on exclusion criteria – explained by quartile deviation from the mean  - Owing to the possibility that they may not have come from the same population, they were excluded from the analysis. What population exactly?? I don’t consider this explanation satisfactory. If you had 3 in a 24 sample, the proportion could maintain in general population.

Even more removing 3 data sets from a set of 27 can definitely influence p values.

Very small sample for 6 subsets

 

4. Discussion

Most of this sections relies on other studies and not on interpreting the results of the actual study

Focus more on interpreting the results.

The author overextends the interpretation of correlational results by implying neural mechanisms and diagnostic applicability without direct neurophysiological data or longitudinal evidence.

It’s a small sample. Stick to associations.

 

5. Conclusions

Overfit  formulated conclusions , some of them unlinked to the results of this cross-sectional study

 

General conclusion

Improve coherence and structure

More a prototype/concept of a self-diagnostic tool

The analysis lacks cofounders integration - cognitive reserve, colour-blindness, etc 

The multiple regression model is likely overfit because the small sample size and insufficient relative to the number of predictors included in the analysis.

Author Response

Response to Reviewer 1

 

Comment 1.1 (Results – Table 3 Description and Unit Reporting)

Reviewer comment: "Check table 3 description carefully (page 8) - M and SD are mixed between SE and SEE. Also check for unitary reporting measurements - you report ms instead of seconds."

Response: We thank the reviewer for identifying these errors. The reviewer is correct—the original text incorrectly described the mean and standard deviation values for SE and SEE. We have corrected this error and standardized the unit reporting throughout the manuscript (changing "366.04 ms" to "366.04 sec" in the outlier description).

Changes made:

Original text (incorrect): "The analysis results showed an average executive function score of 82.31, an average time for SE of 9.08 s, and an average frequency for SEE of 35.67."

Revised text (corrected): "The analysis results showed an average Stroop Effect (SE) of 82.31 seconds (SD = 35.67) and an average Stroop Error Effect (SEE) of 9.08 frequency (SD = 6.31)."

Unit correction: Changed "366.04 ms" to "366.04 sec" in the outlier description.

Location: Results section, Section 3.2 (Cognitive Function), paragraph following Table 3; outlier description paragraph.

 

Comment 1.2 (Interpretation – "Effect of Aging" Language)

Reviewer comment: "The author overextends the interpretation of correlational results by implying neural mechanisms and diagnostic applicability without direct neurophysiological data or longitudinal evidence. It's a small sample. Stick to associations."

(Also raised by Reviewer 2): "The authors also frequently described an 'effect of aging', however given there is no younger control group, nor analysis of the effect of age as a covariate... this wording is misleading."

Response: We appreciate this important methodological point. The reviewers are correct that without a younger control group, we cannot claim "effects of aging"—only patterns observed within our older adult sample. We have revised section headers and language throughout the manuscript to accurately reflect our cross-sectional design.

Changes made:

Section header revisions:

• Methods: "Changes in Motor (Coordination) Function Due to Aging" → "Motor (Coordination) Function in Older Adults"
• Methods: "Changes in Cognitive (Executive) Function Due to Aging" → "Cognitive (Executive) Function Measures"
• Results: "Changes in Motor (Coordination) Function Due to Aging" → "Motor Coordination Function"
• Results: "Changes in Cognitive (Executive) function due to aging" → "Cognitive (Executive) Function"

We have also verified that the Abstract contains no causal claims about aging, appropriately describing associations rather than aging effects.

Location: Methods section (Sections 2.1, 2.2), Results section (Sections 3.1, 3.2), and Abstract.

 

Comment 1.3 (Methods – Study Design, Sampling, Data Gathering, and Outlier Criteria)

Reviewer comments: "Explicitly state study design, sampling procedure. Provide detailed description of data gathering. When, where, how long..."

"Many paragraphs belong in introduction or discussion sections."

"Three were considered outliers... explained by quartile deviation from the mean... I don't consider this explanation satisfactory. What population exactly??"

Response: We appreciate these suggestions for improving reproducibility. We have enhanced the Methods section with procedural details while maintaining our integrated theoretical-methodological presentation. We believe this integrated approach best serves readers by providing immediate context for why each measure was selected, though we have significantly improved the clarity of procedural information.

Changes made:

1. Section header revised: "Participants and Recruitment Process" → "Participants, Procedure, and Data Analysis"
2. Testing location and procedure added: Community center setting with standardized laboratory devices, task order (SRT, AT, SC, AC, then Stroop), and rest periods between tasks
3. Statistical analysis specified: IBM SPSS Statistics (Version 29.0); descriptive statistics, Pearson correlations, and multiple regression with significance threshold (p < 0.05)
4. Outlier criteria clarified: Z-score criterion (±2.5 SD) following Ratcliff (1993) recommendations for reaction time data, with specific z-values reported and reference to Supplementary Materials (Appendix 2.2) for complete details

Location: Methods section, Section 2.3 (Participants, Procedure, and Data Analysis).

 

Comment 1.4 (Statistical Concerns – Sample Size and Model Overfitting)

Reviewer comments: "The multiple regression model is likely overfit because the small sample size and insufficient relative to the number of predictors included in the analysis."

"Very small sample for 6 subsets."

Response:

We acknowledge this important methodological concern. The participant-to-predictor ratio (n = 24 with 6 predictors) falls below commonly recommended thresholds (e.g., 10:1). We have added explicit acknowledgment of this limitation in the Discussion section.

Changes made:

Added to Discussion (Limitations paragraph):

"The sample size (n = 24) relative to the number of predictors in the regression models warrants caution in interpretation. While the participant-to-predictor ratio falls below commonly recommended thresholds (e.g., 10:1), the significant findings for AC, SRT, and AT predicting SEE provide preliminary evidence for targeted investigation in larger samples. The R² value of 0.635 should be interpreted as potentially optimistic; future studies with larger samples should confirm these relationships."

Location: Discussion section, Limitations paragraph (First limitation).

 

Comment 1.5 (Title – Misleading Framing)

Reviewer comment (Reviewer 2): "I find the title quite misleading. I do not understand what is meant by aging profile, given the authors do not explicitly describe an effect of age beyond using an older sample. Furthermore, self-diagnosis similarly could mislead the reader as being self-reported perception, while the authors describe instead a series of motor and cognitive tasks."

Response: We agree that the original title could be misleading. We have revised the title to accurately reflect our cross-sectional design and the nature of our assessment approach.

Changes made:

Original title: "Self-Diagnosis of Aging Profile according to Motor and Cognitive Functions: A Systemic Approach to Diagnosis and Intervention"

Revised title: "Motor-Cognitive Associations in Older Adults: A Cross-Sectional Study Toward Self-Assessment Tools"

Location: Title page.

 

 

Comment 1.6 (Introduction – Length, Aims, and Literature)

Reviewer comments: "Introduction: Quite long. Emphasize the need for making this study and the aim. The aim also needs to clearly define the population under study."

(Reviewer 2): "The references are appropriate, albeit some outdated; the authors could consider including more recent literature to bolster their approach."

Response: We appreciate these suggestions. We have condensed the Introduction while maintaining essential content and added explicit study aims with a clear hypothesis and population definition.

Changes made:

1. Condensed aging statistics paragraph (detailed Korea/Japan/China statistics reduced to concise summary)
2. Merged and streamlined exercise-cognition paragraphs
3. Condensed neurophysiological mechanisms description
4. Added explicit Study Aims paragraph at end of Introduction:

"This cross-sectional study aimed to (1) examine associations between motor coordination abilities (temporal and spatial measures) and cognitive function (Stroop test performance) in community-dwelling older adults aged 71-89 years, and (2) develop a preliminary self-assessment framework that could facilitate early identification of motor-cognitive decline. We hypothesized that asymmetric spatial coordination would show stronger associations with executive function measures than temporal-based coordination tasks."

5. Literature: Recent references (2020-2025) are included throughout (Stojan et al., 2023; Rinn et al., 2023; Gajewski et al., 2020), which adequately supports our approach

Result: Introduction reduced by approximately 150 words while improving clarity.

Location: Background section (Introduction), throughout.

 

Comment 1.7 (Methods – Stroop Formula Reference; Limitations – Confounders)

Reviewer comments: (Reviewer 2): "Reference or explanation of the interference calculation in the methods (Stroop 3 - (S1 + S2) / 2)."

"The analysis lacks confounders integration - cognitive reserve, colour-blindness, etc."

Response: We have addressed both points by adding clarification to the Methods section and acknowledging confounders in the Limitations.

Changes made:

1. Stroop formula explanation added (Methods, Cognitive Function Measures):

"This formula isolates the interference effect by comparing incongruent trial performance to the average of congruent conditions, following standard procedures (MacLeod, 1991)."

2. Confounders acknowledgment added (Discussion, Limitations, Third point):

"Third, this study did not control for potential confounders including cognitive reserve (e.g., occupational complexity, lifetime intellectual engagement), color vision deficits, visual acuity, or depression, which may influence both motor coordination and Stroop test performance."

3. Reference added:

MacLeod, C. M. (1991). Half a century of research on the Stroop effect: An integrative review. Psychological Bulletin, 109(2), 163–203.

Location: Methods section (Cognitive Function Measures); Discussion section (Limitations paragraph); References.

 

Comment 1.8 (Results – Organization and Table Format)

Reviewer comments: "It is difficult to distinguish core findings from secondary or contextual information."

(Reviewer 2): "The results are similarly (dis)organized, as they do not present clear findings from the tasks... It is unusual to present exemplars of the database formatting alongside means and errors, and indeed the results could be more concise and clear if the results were simply illustrated in a table(s) describing the aggregated data."

Response: We appreciate these suggestions for improving results clarity. We have made revisions to highlight core findings while maintaining data transparency.

Changes made:

1. Lead with key finding: Revised the opening of Section 3.3 (Correlation Analysis) to immediately present the primary finding:

"The primary finding was a significant negative correlation between asymmetric spatial coordination (AC) and Stroop error effects (SEE) (r = -0.475, p = 0.033), indicating that better coordination was associated with fewer cognitive errors."

2. Table format maintained with enhanced clarity: We retained individual participant data presentation in Tables 2-4 for transparency in data reporting, which supports reproducibility and allows readers to verify analyses. We have enhanced table notes to clarify that exemplar data is shown with complete data available in Supplementary Materials:

"Exemplar participant data shown; complete individual data available in Supplementary Materials (Appendix 2.1) to support reproducibility."

Location: Results section, Section 3.3 opening paragraph; Table 2 note.

 

Comment 1.9 (Interpretation – Correlational Language and Preliminary Framing)

Reviewer comments: "The author overextends the interpretation of correlational results by implying neural mechanisms and diagnostic applicability without direct neurophysiological data or longitudinal evidence. It's a small sample. Stick to associations."

"More a prototype/concept of a self-diagnostic tool."

Response: We acknowledge this concern and have revised the manuscript to use appropriately cautious, correlational language throughout. We have replaced mechanistic claims with association-based interpretations and reframed the diagnostic model as preliminary/proof-of-concept.

Changes made:

1. Abstract revised:

• "self-diagnostic model" → "preliminary self-assessment framework"
• "diagnostic model" → "preliminary assessment framework"

2. Results section: "diagnostic and prevention model" → "preliminary framework for assessment"
3. Discussion – mechanistic language revised:

• "the brain's synapses and neural tissues are well-maintained and functional" → "better coordination performance may reflect preserved neural function"
• "Coordination exercise acts similarly as a cerebral stimulant" → "Coordination tasks may engage similar neural processes as cognitive tasks"

Location: Abstract; Results section 3.3; Discussion section.

 

Comment 1.10 (Outliers – Sensitivity Analysis and p-value Concerns)

Reviewer comments: "Even more removing 3 data sets from a set of 27 can definitely influence p values."

"If you had 3 in a 24 sample, the proportion could maintain in general population."

Response: We acknowledge this concern regarding the potential impact of outlier exclusion on results. We have added clarification in both the Results and Limitations sections.

Changes made:

1. Results section (after outlier exclusion description): Added statement noting that the exclusion rate is within acceptable ranges and the primary AC-SEE correlation pattern remained consistent in direction.
2. Limitations paragraph (added as Fourth limitation):

"Fourth, while formal sensitivity analyses were not conducted, the exclusion rate (12.5%) is within acceptable ranges for reaction time studies (Ratcliff, 1993), and detailed outlier criteria are reported in Supplementary Materials."

Location: Results section (Section 3.2); Discussion section (Limitations paragraph, Fourth point).

 

Comment 1.11 (Discussion Focus, Conclusions, and Figures)

Reviewer comments: "Most of this section relies on other studies and not on interpreting the results of the actual study. Focus more on interpreting the results."

"Overfit formulated conclusions, some of them unlinked to the results of this cross-sectional study."

(Reviewer 2): "Figure 7, and many of the other figures (e.g., Figure 4.1, 4.2), are simply too small to see at this scale, and make it difficult to interpret... the current models presented are very detailed and perhaps overly complex."

Response: We appreciate these suggestions for improving the focus on our findings. We have restructured the Discussion opening, added a study-specific Conclusions summary, and reorganized figures.

Changes made:

1. Discussion restructured with new opening paragraphs:

Key findings summary:

"This study revealed a significant negative association between asymmetric spatial coordination (AC) and Stroop error effects (SEE) (r = -0.475, p = 0.033) in community-dwelling older adults, with AC emerging as the strongest predictor in the regression model (β = -0.475, R² = 0.635). These findings align with and extend previous work on motor-cognitive relationships."

Interpretation of findings:

"The stronger association of spatial coordination measures (particularly AC) with cognitive errors, compared to temporal measures, suggests that the ability to independently control bilateral limb movements may share underlying processes with executive inhibition. The asymmetric coordination task requires suppression of the natural tendency toward symmetric movement—a demand conceptually similar to the inhibition required in incongruent Stroop trials."

2. Conclusions: Added study-specific summary paragraph at the end of the Conclusions section:

"In summary, this cross-sectional study provides preliminary evidence for associations between motor coordination abilities and cognitive function in older adults. Asymmetric spatial coordination showed the strongest association with Stroop error effects, suggesting potential utility as a component of self-assessment frameworks. The proposed framework should be considered a proof-of-concept requiring validation in larger, longitudinal studies before clinical application."

3. Figures reorganized:

• Original Figure 4.2 (detailed scatter plots) moved to Supplementary Materials as Appendix 2.3 to reduce density in the main text
• Original Figure 4.1 renumbered as Figure 4
• Figure 7 (conceptual model) retained but modified appropriately corresponding to the reviewer’s point in main text as it represents the core theoretical contribution of the study—the integrated motor-cognitive diagnostic framework

Location: Discussion section (opening paragraphs); Conclusions section (final paragraph); Figures and Supplementary Materials.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript, in which the authors described a study of motor and cognitive function in an older population. The authors use a variety of cognitive and motor tasks to quantify age-related impacts on functioning, and present results showing the relationship between coordination tasks with executive functioning. The authors are commended on a very thorough and justified study, however the manuscript suffers from organizational issues and structural complexity, largely owing to the large number of results and analyses that needs to be addressed to be suitable for publication.

I outline these concerns below.

Title: I find the title quite misleading. I do not understanding what is meant by aging profile, given the authors do not explicitly describe an effect of age beyond using an older sample. Furthermore, self-diagnosis similarly could mislead the reader as being self-reported perception, while the authors describe instead a series of motor and cognitive tasks. 

Introduction:

The primary concern with the presentation of this much (variable) data, is that the manuscript itself lacks a clear structure. The background introduces the rational for the topic well, and the references are appropriate, albeit some outdated; the authors could consider including more recent literature to bolster their approach. 

Methods:

The methods section does not follow a typical flow, and thus is quite confusing at times as to the definition of the variables collected, how they were collected, and in what setting. Typically, the justification or background of such variables and tests is mentioned in the introduction, as justification for the approach, the research question, and expected outcomes. Here, The methods include lengthy descriptions of the origins and theoretical bases for the outcome measures, but no clear description of the actual methods used. For this purpose, the methods in their current state would be difficult to reproduce. The authors should consider a more logical structure, which adhered to methodological descriptions for the purpose of clarity and reproducibility, as opposed to a justification and theoretical discussion.

 

Results:

The results are similarly (dis)organized, as they do not present clear findings from the tasks, not clear structured approach to the answering the research question. It is unusual to present exemplars of the database formatting alongside means and errors, and indeed the results could be more concise and clear if the results were simply illustrated in a table(s) describing the aggregated data. 

The authors also frequently described an 'effect of aging', however given there is no younger control group, nor analysis of the effect of age as a covariate that I could see, this wording is misleading. The results do capture patterns in an older sample, but to state an effect of aging requires a reference category or age regression, which would likely be difficult in a small sample with a relatively small age range. 

Discussion:

Figure 7, and many of the other figures (e.g., Figure 4.1, 4.2), are simply too small to see at this scale, and make it difficult to interpret. I commend the authors for the depth of their work, but the current models presented are very detailed and perhaps overly complex in this graphical depiction.  

Minor:

Missing space "areasrelated" in the introduction penultimate paragraph.

Reference or explanation of the interference calculation in the methods (Stroop 3 - (S1 + S2) / 2)

What were the exclusion criteria by which the three participants were considered outliers? Typically designating a participant as an outlier is no the same as excluding due to failed criteria. 

Author Response

Response to Reviewer 2

We thank Reviewer 2 for the thorough and constructive feedback, and for commending our study as "very thorough and justified." Many of Reviewer 2's comments overlapped with Reviewer 1's concerns, which we have addressed above. Below we summarize how each of Reviewer 2's specific points has been addressed:

Title concerns ("misleading", "aging profile", "self-diagnosis")

Addressed in Comment 1.5. Title revised to: "Motor-Cognitive Associations in Older Adults: A Cross-Sectional Study Toward Self-Assessment Tools."

Introduction – outdated references and structure

Addressed in Comment 1.6. Recent references (2020-2025) are included: Stojan et al. (2023), Rinn et al. (2023), Gajewski et al. (2020). Study aims and population clearly defined.

Methods – structure, reproducibility, and variable definitions

Addressed in Comments 1.3 and 1.7. Procedural details added (setting, task order, statistical software). Stroop interference formula explained with MacLeod (1991) citation. Outlier criteria clarified with specific z-score values.

"Effect of aging" wording – misleading without younger control group

Addressed in Comment 1.2. All section headers revised to remove causal aging language. Now describes "patterns in older adults" rather than "effects of aging."

Results – organization and database exemplars

Addressed in Comment 1.8. Results now lead with key finding (AC-SEE correlation). Table format maintained for transparency with enhanced notes referencing Supplementary Materials for complete data.

Figure sizing (Figures 4.1, 4.2, 7 – "too small to see")

Addressed in Comment 1.11. Figure 4.2 moved to Supplementary Materials (Appendix 2.3) to reduce main text density. Figure 4.1 renumbered as Figure 4. Figure 7 retained in main text with improved and modified formatting as the core theoretical contribution.

Outlier criteria clarification

Addressed in Comments 1.3 and 1.10. Z-score criterion (±2.5 SD) now specified following Ratcliff (1993). Detailed values provided in Supplementary Materials (Appendix 2.2). Exclusion rate (12.5%) acknowledged as within acceptable ranges.

Stroop interference calculation – reference needed

Addressed in Comment 1.7. Formula explanation added with MacLeod (1991) citation: "This formula isolates the interference effect by comparing incongruent trial performance to the average of congruent conditions."

Minor: "areasrelated" typo

Fixed. Now reads "areas related" in the Introduction.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Substantially improved version.

I maintain my concerns on the multiple regression model due to a small sample size and insufficient relative to the number of predictors included in the analysis.

Reviewer 2 Report

Comments and Suggestions for Authors

I am satisfied with these revisions.