# An Integrated Program to Improve Cognitive and Physical Abilities in Older People
## 2 Literature Review
### Stroop Stepping Game  
This study builds on the work of [PERSON] et al. [30], extending it by incorporating the Stroop effect into the four-way stepping game. This effect refers to the phenomenon whereby when the meaning of a letter and its actual color do not match, people take longer to name the color of the letter and are more often incorrect in their naming. This effect is called Stroop interference; in particular, it is called Stroop congruence when the letters and colors match and the Stroop mismatch when they do not. The Stroop task, which is an application of the Stroop effect, is used to measure working memory and executive function in older people, and it is effective in cognitive enhancement [31]. In addition, gamified step training is effective in improving stepping and walking ability in older people and in improving balance and preventing falls in older people [27; 32].  
In this study, we defined a task combining these two elements as the Stroop Stepping Game (SSG). While previous studies only measured improvement of walking ability, this study further analyzed the improvement of cognitive and physical performance, including walking ability. The SSG involves viewing a shape and color combination task on a display and stepping in all directions on a footstool matching the shape or the color of the shape. While the typical Stroop task is a color-naming task requiring participants to name the color of a presented letter, this study used a shape and color combination instead of a letter and color combination to make the task more intuitive for older adults, who may be illiterate and/or colorblind. A prototype of the Stroop Stepping Game (SSG) is presented as shown in Figure 1.  
In previous studies, four-way stepping games were primarily conducted using digital devices. Rhythmic step exercises, such as Dance Dance Revolution (DDR), have been shown to improve balance in older adults [33] and the four-way stepping test using a digital device is a way to measure changes in fall rates and improve fall efficacy [34]. However, most previous studies have focused on changes in either physical performance or cognitive function independently, with few examining the effects on both physical and cognitive functions simultaneously. Therefore, this study seeks to determine whether an exercise program that combines four-way step training with cognitive task, such as the Stroop effect, can lead to improvements in both cognition and performance. Previous studies using four-way step training or the Stroop effect have been characterized by the following key features (Table 1).  
This study differs from previous studies in the following ways:  
* This study is conducted as an offline program using experimental tools that are easy to make and cost-effective.
* It utilizes the Stroop task, which has been used to measure cognitive function, as one of the contents to check further whether cognitive function improves in addition to physical performance and physical ability.
* It considers the characteristics of older adults who may be illiterate and color-blind; the traditional Stroop task has been modified to use shape + color combinations instead of letter + color combinations.
* It gradually increases the position and spacing of prop-type step stools to see if this improves walking ability and stamina.
* It uses gamification strategies to increase motivation and persistence and quantitatively verify that the experiment had an impact on older adults' satisfaction after the experiment.  
Figure 1: Stroop Stepping Game (SSG).