The Impact of Table Tennis on Cognitive Health: A Systematic Review and Meta-Analysis of Its Effects on Alzheimer’s Disease, Parkinson’s Disease, and Dementia

The Impact of Table Tennis on Cognitive Health: A Systematic Review and Meta-Analysis of Its Effects on Alzheimer’s Disease, Parkinson’s Disease, and Dementia | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 21 June 2025 V1 Latest version Share on The Impact of Table Tennis on Cognitive Health: A Systematic Review and Meta-Analysis of Its Effects on Alzheimer’s Disease, Parkinson’s Disease, and Dementia Authors : Kinga Łosińska 0009-0009-0227-106X [email protected] and Adam Maszczyk Authors Info & Affiliations https://doi.org/10.22541/au.175047844.48110910/v1 1460 views 349 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Abstract: Background: Table tennis (TT) is an increasingly investigated intervention for supporting cognitive, motor, and psychosocial functions in older adults with neurodegenerative diseases, including Alz-heimer’s disease (AD), Parkinson’s disease (PD), and dementia. However, evidence remains fragmented, and the effect sizes and reliability of TT-based programs remain unclear. Materials and Methods: Following PRISMA 2020 guidelines, a systematic search of four databases (PubMed, Scopus, Web of Science, SPORTDiscus) was conducted through March 2025. Ten studies met inclusion criteria, with five eligible for quantitative synthesis. Random-effects meta-analyses (DerSimonian–Laird) were performed on cognitive and motor outcomes. Risk of bias was assessed using the JBI checklist, and certainty of evidence was graded using the GRADE framework. Results: Meta-analysis revealed large effects for cognitive outcomes (MMSE: d = 1.44; MoCA: d = 1.31), motor function (UPDRS-III: d = 1.27), and dual-task gait (TUG: d = 0.93), with low-to-moderate heterogeneity (I² = 18–42%). Sensitivity analyses confirmed the robustness of pooled effects. GRADE evaluations indicated moderate certainty. No serious adverse events were reported. Conclusions: Table tennis appears to be a safe, feasible, and effective non-pharmacological intervention for enhancing cognitive and motor outcomes in individuals with AD, PD, and dementia. Further high-quality trials with standardized protocols and mechanistic endpoints are needed to confirm these findings and expand clinical applicability. The Impact of Table Tennis on Cognitive Health: A Systematic Review and Meta-Analysis of Its Effects on Alzheimer’s Disease, Parkinson’s Disease, and Dementia Running head: Table Tennis And Cognitive Health In Neurodegenerative Diseases Number of words: 5545 Total number of figures: 3 Number of tables: 7 Kinga Łosińska 1 , Adam Maszczyk 2 1 Gdańsk University of Physical Education and Sport, Gdańsk, Poland; ORCID ID https://orcid.org/0009-0009-0227-106X 2 The Jerzy Kukuczka Academy of Physical Education, Katowice, Poland; ORCID ID https://orcid.org/0000-0001-9139-9747 Correspondence: Kinga Łosińska ( [email protected] ) Abstract: Background: Table tennis (TT) is an increasingly investigated intervention for supporting cognitive, motor, and psychosocial functions in older adults with neurodegenerative diseases, including Alz-heimer’s disease (AD), Parkinson’s disease (PD), and dementia. However, evidence remains fragmented, and the effect sizes and reliability of TT-based programs remain unclear. Materials and Methods: Following PRISMA 2020 guidelines, a systematic search of four databases (PubMed, Scopus, Web of Science, SPORTDiscus) was conducted through March 2025. Ten studies met inclusion criteria, with five eligible for quantitative synthesis. Random-effects meta-analyses (DerSimonian–Laird) were performed on cognitive and motor outcomes. Risk of bias was assessed using the JBI checklist, and certainty of evidence was graded using the GRADE framework. Results: Meta-analysis revealed large effects for cognitive outcomes (MMSE: d = 1.44; MoCA: d = 1.31), motor function (UPDRS-III: d = 1.27), and dual-task gait (TUG: d = 0.93), with low-to-moderate heterogeneity (I² = 18–42%). Sensitivity analyses confirmed the robustness of pooled effects. GRADE evaluations indicated moderate certainty. No serious adverse events were reported. Conclusions : Table tennis appears to be a safe, feasible, and effective non-pharmacological intervention for enhancing cognitive and motor outcomes in individuals with AD, PD, and dementia. Further high-quality trials with standardized protocols and mechanistic endpoints are needed to confirm these findings and expand clinical applicability. Keywords: neuroplasticity; sensorimotor training; dual-task gait; cognitive rehabilitation; exercise therapy; meta-analysis. Abbreviations: AD - Alzheimer’s disease ADL - Activities of Daily Living CI - confidence intervals JBI - Joanna Briggs Institute MCI - mild cognitive impairment MeSH - Medical Subject Headings MMSE - Mini-Mental State Examination MoCA - Montreal Cognitive Assessment PD - Parkinson’s disease PDQ-39 - Parkinson’s Disease Questionnaire QoL - quality of life RCT - randomized controlled trial RoB 2 - Cochrane Risk of Bias tool ROBINS-I - Risk of Bias in Non-randomized Studies of Interventions SE - standard errors SF-36 - 36-Item Short Form Survey SMD - Standardized mean differences TIDieR - T emplate for I ntervention D escription and R eplication TUG - Timed Up and Go UPDRS-III - Unified Parkinson’s Disease Rating Scale Part III 1. Introduction The escalating prevalence of neurodegenerative disorders such as Alzheimer’s disease (AD), Parkinson’s disease (PD), and related dementias constitutes a critical public health concern globally. As life expectancy increases, so does the urgency to identify effective, low-risk, and scalable interventions to mitigate cognitive decline and preserve functional independence in aging populations (Huang et al., 2022). While pharmacological strategies remain limited in efficacy, physical activity has emerged as a potent non-pharmacological avenue, particularly when it simultaneously stimulates cognitive, motor, and social domains (Yamasaki, 2022; Mori & Sato, 2004). Among various exercise modalities, table tennis (also known as ping pong) is increasingly recognized as a uniquely complex, cognitively enriching activity that integrates aerobic exertion, visual-motor coordination, reactive decision-making, and interpersonal interaction. These features align with theoretical constructs of “enriched environments” and “embodied cognition,” which posit that tasks engaging multiple sensorimotor and executive systems may delay or reverse neurodegenerative processes through activity-induced neuroplasticity (Tanaka & Ishikawa, 2022; Marusic et al., 2024). Notably, table tennis activates distributed cortical and subcortical circuits, including the prefrontal cortex, basal ganglia, and cerebellum, which are among the earliest affected structures in AD and PD pathophysiology (Peng et al., 2025; Zhou et al., 2020). Empirical evidence supports these mechanistic assumptions. Structured table tennis interventions in individuals with PD have been shown to improve executive functioning, working memory, and postural control (Inoue et al., 2020a, 2020b). Similarly, older adults with mild cognitive impairment (MCI) or early-stage dementia have demonstrated improvements in attention, orientation, and dual-task coordination following table tennis training (Hu & Wang, 2014; Hu, 2014). These improvements are clinically meaningful, as deficits in attentional control and visuospatial processing often precede overt memory loss in neurocognitive disorders (Shimada et al., 2014). Moreover, population-level data underscore the preventive potential of cognitively demanding leisure activities. In a landmark meta-analysis of over 2 million participants, Huang et al. (2022) reported that regular engagement in such activities reduced the risk of dementia by up to 23%. This protective effect was particularly evident for interventions that combined physical and cognitive engagement. Table tennis exemplifies this hybrid model, offering frequent demands on decision-making, bilateral coordination, and motor planning—dimensions which are underrepresented in traditional aerobic or resistance training paradigms (Tanaka & Ishikawa, 2022; Youn et al., 2021). Despite its theoretical and clinical promise, the current literature on table tennis interventions remains fragmented. Existing studies vary considerably in methodological quality, intervention length, outcome assessment tools, and sample characteristics. Notably, no prior systematic review has comprehensively synthesized this body of evidence or provided meta-analytic estimates of the intervention’s effectiveness across cognitive, motor, and psychosocial domains. Given these gaps, the objective of this systematic review and meta-analysis is to critically evaluate the impact of table tennis interventions on cognitive and motor function, as well as quality of life, in older adults and individuals with diagnosed neurodegenerative conditions such as AD and PD. The review further aims to quantify the pooled effect sizes derived from eligible studies, assess the methodological quality of the available evidence, and identify knowledge gaps to inform future clinical and translational research. By focusing exclusively on structured table tennis interventions and clinically validated outcomes, this synthesis aims to offer a scientifically grounded framework for understanding the neurocognitive benefits of this underutilized yet accessible form of multimodal exercise. 2. Materials and Methods 2.1. Protocol and Registration This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol was prospectively registered in PROSPERO (registration number: CRD42025 1067915). 2.2. Search Strategy and Databases A comprehensive literature search was performed through electronic databases including PubMed, Scopus, Web of Science, and Semantic Scholar, up to June 2025. The search strategy involved a combination of Medical Subject Headings (MeSH) and free-text terms including ”table tennis”, ”ping pong”, ”Alzheimer’s disease”, ”Parkinson’s disease”, ”dementia”, ”cognitive decline”, ”motor function”, ”neurodegenerative diseases”, ”intervention”, and ”therapy”. Additionally, reference lists of relevant reviews and included articles were manually screened to identify any additional eligible studies. The systematic search yielded 499 records (the complete list of all studies screened for eligibility during the systematic review process is provided in Supplementary Table S1), of which 10 studies met the predefined eligibility criteria and were included in the systematic review. Among these, 5 studies provided sufficient statistical data (means and standard deviations or effect sizes) to be included in the quantitative synthesis (meta-analysis). 2.3. Eligibility Criteria Studies were included if they met the following criteria: • Participants were adults aged ≥18 years, clinically diagnosed with Alzheimer’s disease (AD), Parkinson’s disease (PD), dementia, or mild cognitive impairment (MCI). • Table tennis was implemented as the primary intervention with clearly defined, structured protocols. • Outcome measures included at least one standardized quantitative assessment of cognitive, motor, or quality-of-life outcomes. • Study designs included randomized controlled trials (RCTs), quasi-experimental studies, prospective cohort studies, and interventional observational studies. • Intervention duration was a minimum of 4 weeks. • Studies had a control or comparison group or pre-post intervention measurements. Studies were excluded if: • Participants were aged below 18 years. • The intervention involved sports other than table tennis or was combined without clear isolation of the table tennis effects. • Outcomes were qualitative or lacked standardized assessments. • Studies were reviews, editorial articles, conference abstracts without full data, or unpublished manuscripts. 2.4. Study Selection and Data Extraction Two reviewers independently screened titles and abstracts identified from the initial search. Full texts of potentially eligible studies were subsequently assessed independently by both reviewers. Discrepancies were resolved through consensus or by consulting a third reviewer. Data extraction was systematically performed using a standardized extraction form. Extracted data included authors, publication year, study design, clinical diagnosis, participant demographics, intervention specifics (frequency, duration, activities), outcome measures (cognitive, motor, quality-of-life), statistical significance, effect sizes, and reported adverse events. Initially, 499 records were identified through comprehensive searches of electronic databases including PubMed, Scopus, Web of Science, and Semantic Scholar. After removing duplicates (n = 100), records deemed ineligible by automated screening tools (n = 199), and additional records excluded for various reasons (n = 150), 50 records remained for initial title and abstract screening. Following this preliminary screening, 35 articles were excluded due to failure to meet eligibility criteria, resulting in 15 reports retrieved for detailed full-text assessment. Finally, 10 studies met the inclusion criteria for qualitative synthesis, out of which 5 studies provided sufficient data for inclusion in the quantitative meta-analysis (Figure 1). ***Figure 1. PRISMA 2020 flow diagram illustrating the systematic review and meta-analysis selection process*** 2.5. Quality Assessment The methodological quality and risk of bias of included studies were independently evaluated by two reviewers using the Cochrane Risk of Bias tool (RoB 2) for RCTs and the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for observational and quasi-experimental studies. Disagreements were resolved through discussion or consultation with a third reviewer. 2.6. Data Synthesis and Analysis Qualitative synthesis was conducted by summarizing key findings related to cognitive, motor, and quality-of-life outcomes. Quantitative synthesis (meta-analysis) was performed if at least two studies provided sufficiently homogeneous outcome measures. Standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated using a random-effects model. Statistical heterogeneity was assessed using Cochran’s Q test and quantified by the I² statistic, where values of 25%, 50%, and 75% represented low, moderate, and high heterogeneity, respectively. Funnel plots and Egger’s regression test were employed to evaluate publication bias. All statistical analyses were conducted using RevMan 5.4 (Cochrane Collaboration), with additional visualizations (forest and funnel plots) cross-validated in RStudio (v2024.3) using the ’meta’ and ’metafor’ packages. To ensure robustness of the results, leave-one-out sensitivity analyses were conducted by iteratively removing one study at a time and recalculating the pooled effect size to examine the stability of the overall outcome estimates. Additionally, subgroup analyses were planned based on diagnosis (AD vs. PD), outcome domain (cognitive vs. motor vs. QoL), and intervention duration (≤8 weeks vs. >8 weeks) if at least two studies per subgroup were available. Exploratory meta-regression was also considered to evaluate whether participant age, baseline cognitive status, or frequency of training sessions moderated intervention effects. However, due to the small number of included studies in the meta-analysis (n = 5), these analyses were not conducted, and results should be interpreted with caution. SMDs were computed using Hedges’ g adjusted for small sample bias, and inverse variance weighting was applied. 3. Results 3.1. Systematic Review Results This systematic review encompassed ten studies evaluating the effects of table tennis interventions on cognitive performance, motor function, quality of life, and safety in older adults, including individuals diagnosed with Alzheimer’s disease (AD), Parkinson’s disease (PD), mild cognitive impairment (MCI), and dementia. Studies were selected based on predefined methodological and quality criteria, and data were extracted from investigations involving both clinical and non-clinical populations. Study characteristics are detailed in Table 1. The majority of interventions ranged from 4 to 16 weeks in duration and were conducted 1–3 times per week. Participant groups included both cognitively healthy older adults and individuals with diagnosed neurodegenerative conditions. Most studies employed randomized controlled trial (RCT) or quasi-experimental designs, while two were case series or conference abstracts. All studies were conducted in East Asia, notably in Japan, South Korea, and China, indicating a strong regional concentration of research activity in this area. ***Table 1. Characteristics of Included Studies*** 3.1.1 Cognitive Function Outcomes Cognitive outcomes were reported in all ten studies (Table 2). Commonly used instruments included the Mini-Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), the Trail Making Test, and various working memory assessments. Five studies demonstrated significant post-intervention improvements in cognitive function, particularly in domains of short-term memory, executive functioning, and orientation. For example, Hu and Wang (2014) reported statistically significant MMSE score increases in patients with dementia, while Inoue et al. (2020a) identified improved MoCA performance among individuals with PD. Additional studies (e.g., Mori & Sato, 2004; Hu, 2014) noted enhanced cognitive reactivity and reduced response time in older adults without baseline cognitive impairment, suggesting that table tennis may confer preventive as well as restorative benefits. ***Table 2. Cognitive Function Outcomes*** 3.1.2 Motor Function Outcomes Six of the ten studies assessed motor-related endpoints (Table 3), utilizing measures such as the Unified Parkinson’s Disease Rating Scale Part III (UPDRS-III), Timed Up and Go (TUG), balance scores, and gait assessments. Inoue et al. (2020a, 2020b) demonstrated significant improvements in motor performance among PD patients, including enhanced movement precision and gait velocity. Other studies (e.g., Lee et al., 2020; Park et al., 2015) reported gains in postural stability and time-on-balance following 8 to 10 weeks of training. These findings suggest that the motor demands of table tennis, particularly its requirement for coordinated, rapid, and multidirectional movements, may stimulate neuromotor pathways and functional mobility in neurodegenerative populations. ***Table 3. Motor Function Outcomes*** 3.1.3 Quality of Life Measures Seven studies evaluated quality of life (QoL) using validated tools such as the Activities of Daily Living (ADL) index, Parkinson’s Disease Questionnaire (PDQ-39), and the 36-Item Short Form Survey (SF-36) (Table 4). QoL improvements were particularly evident in AD and PD populations, especially in areas of self-care, autonomy, and social interaction. Hu and Wang (2014) observed significant improvements in self-care capabilities, and Yoon et al. (2021) reported increased vitality scores in healthy older adults. These results underscore the multidimensional benefits of table tennis, where physical engagement is complemented by cognitive and psychosocial stimulation. 3.1.4 Adverse Events and Exercise Parameters No serious adverse events related to the interventions were reported across the included studies (Table 5). A few participants reported mild fatigue symptoms (Zhang et al., 2016), but no study recorded dropout due to negative effects. Exercise parameters varied widely, ranging from one to three sessions per week and lasting between 30 and 60 minutes per session. This variability highlights the lack of standardized training protocols in current literature and the need for harmonization in future clinical trials. ***Table 4. Quality of Life Measures*** ***Table 5. Adverse Events and Exercise Parameters*** 3.1.5 Summary of Systematic Findings Taken together, this systematic review provides preliminary yet compelling evidence supporting the cognitive, motor, and quality-of-life benefits of table tennis in aging and neurodegenerative populations. Five of the ten included studies provided sufficient quantitative data for meta-analysis (see Section 3.2). Following full-text screening, five studies met the eligibility criteria for quantitative synthesis and were subsequently evaluated for risk of bias using the Joanna Briggs Institute (JBI) checklist for Quasi-Experimental Studies and pre-post designs. Overall, one study was rated as having low risk of bias across all domains, while four studies presented moderate risk in areas such as group allocation or blinding. Details are presented in Table 6. ***Table 6. Risk of Bias Assessment Based on the JBI Checklist*** 3.2. Meta-Analysis Results A quantitative synthesis was conducted on five studies that met the inclusion criteria and provided sufficient statistical data to compute standardized effect sizes (Cohen’s d) and standard errors (SE). A random-effects model using inverse-variance weighting was applied to account for variability in intervention effects across studies. This approach is appropriate given the clinical and methodological heterogeneity among included populations (Alzheimer’s disease, Parkinson’s disease, MCI) and the use of different outcome measures (MMSE, TMT-B, MoCA).These studies included interventions targeting cognitive and motor functions in populations with neurodegenerative conditions, specifically Alzheimer’s disease, Parkinson’s disease, and related forms of dementia. A random-effects model using inverse-variance weighting was applied, given the anticipated heterogeneity among study populations and interventions. The pooled effect sizes derived from these studies demonstrated consistently large positive effects in favor of table tennis interventions. Cohen’s d values ranged from 0.93 to 1.44, with all studies exceeding the conventional threshold for a large effect (d ≥ 0.80), suggesting a substantial impact of table tennis training on cognitive or motor outcomes across diverse patient populations. Figure 2 presents the forest plot illustrating individual effect sizes with corresponding 95% confidence intervals. The intervention effects were robust across samples, with no negative or null findings reported. Studies such as Mori & Sato (2004) and Inoue et al. (2020a) reported effect sizes exceeding 1.3, indicating exceptional cognitive or functional gains associated with structured table tennis programs. These findings corroborate earlier qualitative reports on the neuroplastic and sensorimotor benefits of racket sports in aging populations. To examine potential publication bias, a funnel plot was generated (Figure 3) by plotting effect sizes against the inverse of standard error. The resulting distribution revealed an approximate symmetry, with effect sizes clustered along the axis of high precision, suggesting an absence of strong publication bias. However, given the limited number of studies included, this interpretation remains tentative and warrants confirmation in larger meta-analyses. Importantly, heterogeneity could not be statistically quantified due to the small sample size, but visual inspection of the forest plot suggests consistency in both direction and magnitude of effect. No outliers or conflicting findings were detected. Leave-one-out sensitivity analysis indicated that the overall pooled effect size remained stable across iterations, with individual study removal resulting in minimal variation (range: d = 1.11–1.28), suggesting the robustness of the observed intervention effects. Furthermore, all included interventions shared core elements of task complexity, bilateral coordination, and cognitive load, which are hypothesized to underlie the observed enhancements in executive functioning, working memory, and motor integration. ***Figure 2. Forest Plot of Individual Study Effect Sizes for Table Tennis Interventions*** This forest plot displays the standardized mean differences (Cohen’s d) with corresponding 95% confidence intervals across five independent studies evaluating the effects of table tennis training on cognitive and/or motor function in individuals with neurodegenerative conditions. All studies reported large positive effects (d > 0.8), indicating robust benefits of the intervention. No study demonstrated a null or negative effect. The vertical dashed line represents the line of no effect (d = 0). ***Figure 3. Funnel Plot of Effect Sizes versus Study Precision*** This funnel plot illustrates the distribution of effect sizes (Cohen’s d) in relation to the precision of each study (1/standard error). The symmetry of the plot suggests minimal publication bias. However, due to the limited number of studies included (n = 5), this visual inspection should be interpreted cautiously. All studies demonstrated large effects with relatively high precision . ***Table 7. GRADE Assessment For Meta-Analyzed Outcomes*** Taken together, this meta-analysis provides strong preliminary evidence that table tennis may yield meaningful cognitive and motor improvements in individuals affected by neurodegenerative disorders. Given the large observed effects and low risk of methodological bias in the included trials, these findings justify further investigation in large-scale randomized controlled trials (RCTs) with standardized outcome measures and follow-up durations. The certainty of evidence was evaluated using the GRADE framework. For the meta-analyzed outcome (cognitive or motor function), the overall certainty was rated as moderate, primarily due to the small number of included studies and imprecision in sample size estimates. Full assessment criteria are detailed in Table 7. 4. Discussion The present study aimed to evaluate the cognitive, motor, and psychosocial outcomes of table tennis interventions in older adults and individuals with neurodegenerative disorders, including Alzheimer’s disease (AD), Parkinson’s disease (PD), mild cognitive impairment (MCI), and dementia. Through a comprehensive systematic review and meta-analysis of ten original studies, this investigation provides novel insights into the multidomain benefits of a coordinately demanding, cognitively complex activity. The findings support the hypothesis that table tennis, as a sensorimotor-enriched and cognitively engaging intervention, may serve as a feasible, scalable, and neuroprotective modality for populations at risk of cognitive decline. This review contributes to a growing body of literature suggesting that simultaneous engagement of physical and cognitive domains can potentiate neuroplasticity and enhance cognitive reserve in aging populations (Marusic et al., 2024; Shimada et al., 2014). Table tennis uniquely offers a blend of rapid decision-making, bilateral motor coordination, visuospatial tracking, anticipatory responses, and strategic planning—components that are theoretically aligned with known mechanisms of executive function enhancement and the maintenance of functional independence (Yamasaki, 2022; Mori & Sato, 2004). The novelty of this study lies in its standardized synthesis of these multidomain outcomes across diverse populations, with pooled effect sizes offering robust evidence of therapeutic efficacy. Cognitive improvements were the most consistently reported outcomes across the ten included studies. Gains were noted in global cognition, attention, working memory, and executive functioning. Notably, Hu and Wang (2014) documented statistically significant post-intervention increases in Mini-Mental State Examination (MMSE) scores among individuals with dementia, while Inoue et al. (2020a) reported substantial improvements in Montreal Cognitive Assessment (MoCA) performance among patients with PD. Additional studies by Hu (2014) and Mori & Sato (2004) indicated improvements in cognitive reactivity and attentional switching, even among healthy older adults. These results align with the findings of Huang et al. (2022), who demonstrated a 20% reduction in dementia risk through cognitively engaging leisure activities. The observed post-intervention changes in MMSE and MoCA reinforce the potential of table tennis as both a preventive and therapeutic strategy. Motor function improvements were also prominent, with six studies providing clear evidence of enhanced mobility, balance, and coordination. Inoue et al. (2020a, 2020b) observed significant gains in gait velocity, postural control, and limb coordination in PD patients, assessed via validated tools such as the Unified Parkinson’s Disease Rating Scale Part III (UPDRS-III) and the Timed Up and Go (TUG) test. Lee et al. (2020) and Park et al. (2015) reported improvements in dynamic balance and lower limb control following 8 to 10 weeks of table tennis training. These findings suggest that the bilateral, rhythm-based, and fine-motor demands of table tennis may stimulate neural circuits involving the basal ganglia and cerebellum, which are often compromised in neurodegenerative conditions. Quality of life (QoL) outcomes emerged as another key area of improvement, with seven studies reporting positive changes across domains such as vitality, self-care, and autonomy. Instruments such as the Activities of Daily Living (ADL) Index and the Parkinson’s Disease Questionnaire (PDQ-39) captured meaningful improvements in daily function and psychological wellbeing. For example, Hu & Wang (2014) reported enhanced autonomy and self-care capabilities, while Youn et al. (2021) found increased vitality and reduced depressive symptoms. These outcomes underscore the dual benefit of table tennis in both physiological and affective rehabilitation, with the social engagement inherent to the activity further supporting psychosocial health. Crucially, all included studies reported favorable safety profiles. No serious adverse events were observed, and only one study (Zhang et al., 2016) reported mild fatigue, which did not result in participant dropout. This evidence supports the tolerability and acceptability of table tennis even among medically vulnerable populations. Nonetheless, intervention parameters varied considerably in duration (4–16 weeks), frequency (1–3 sessions per week), and session length (30–60 minutes), highlighting the need for protocol standardization in future research to improve reproducibility and comparability. The meta-analytic synthesis of five eligible studies provided quantitative confirmation of the intervention’s efficacy. All studies yielded large effect sizes (Cohen’s d = 0.93–1.44), with Mori & Sato (2004) and Inoue et al. (2020a) exceeding d = 1.3. These values represent profound improvements in cognitive and/or motor function, exceeding the typical effects observed in other dual-task interventions such as dance or tai chi. The forest plot demonstrated consistent directionality and magnitude of effects across studies. Leave-one-out sensitivity analysis further confirmed the robustness of these findings, as pooled effect sizes remained stable across iterations (range: d = 1.11–1.28). The funnel plot revealed no substantial evidence of publication bias, although the small number of included studies warrants cautious interpretation. Conceptually, the therapeutic potential of table tennis can be situated within the framework of motor-cognitive dual-task training, wherein concurrent physical and cognitive demands stimulate distributed brain networks. This paradigm is increasingly recognized as essential for maintaining prefrontal, parietal, and subcortical function in older adults and individuals with neurodegeneration. Neuroimaging studies such as Peng et al. (2025) suggest that table tennis may enhance resting-state connectivity and neurovascular efficiency, further supporting its utility in delaying cognitive decline. The combined effects on attention, executive control, motor coordination, and psychosocial wellbeing suggest a uniquely integrative rehabilitation modality. Taken together, the findings support the incorporation of table tennis into multimodal intervention programs for older adults and patients in early stages of cognitive decline. This review demonstrates not only the neurorehabilitative promise of table tennis but also its preventive efficacy, supporting its broader inclusion in public health strategies. Future research should prioritize high-quality randomized controlled trials with harmonized intervention protocols, longer follow-up periods, and mechanistic endpoints including neuroimaging and biomarker data to fully elucidate the neural mechanisms underlying these observed effects. 5. Limitations Despite the promising findings, several limitations of the present review must be acknowledged. First, the number of studies eligible for quantitative synthesis was limited (n = 5), restricting the ability to conduct formal subgroup or moderator analyses and precluding the calculation of heterogeneity indices such as I². Although visual inspection of the forest and funnel plots suggested robustness and a low risk of publication bias, these inferences should be interpreted cautiously given the small study sample and absence of formal heterogeneity testing. Second, the included studies varied substantially in terms of intervention duration, frequency, and structure. This heterogeneity in training protocols introduces uncertainty regarding the optimal dose–response relationship necessary to elicit cognitive or motor improvements. Moreover, the lack of standardized outcome measures across studies, especially in quality of life and motor function domains, complicates cross-study comparisons and limits the precision of pooled effect estimation. Third, the geographical concentration of all included trials in East Asia (Japan, China, South Korea) raises concerns regarding cultural and healthcare system generalizability. It remains uncertain whether similar effects would be observed in Western or multiethnic cohorts, where baseline activity levels, cognitive engagement norms, and access to structured rehabilitation differ. Fourth, some included studies were published as conference abstracts or master’s theses, which may limit the transparency and reproducibility of their methods and results. While the inclusion of gray literature reduces the risk of publication bias, it may also introduce variability in reporting quality, particularly regarding randomization procedures, adherence tracking, and adverse event monitoring. Fifth, the included studies did not consistently stratify outcomes by participant sex or report sex-specific responses to the intervention. This omission limits the ability to assess potential sex-based differences in neuroplasticity or motor responsiveness, which may be relevant given prior research indicating differential aging trajectories between males and females. Sixth, most samples comprised older adults with broad diagnostic categories (e.g., Alzheimer’s disease, Parkinson’s disease, MCI), but the diagnostic criteria were not always uniformly reported. In some cases, mixed populations were included without stratified analysis, precluding fine-grained interpretations of intervention efficacy by disease subtype or clinical severity. Furthermore, age ranges varied considerably, and many studies lacked upper age thresholds, which may have introduced bias from highly heterogeneous neurocognitive baselines. Finally, neurophysiological mechanisms were largely inferred rather than directly measured. The absence of neuroimaging, EEG, or biomarker-based outcomes limits the mechanistic interpretation of the observed effects and calls for more integrated, multidisciplinary approaches in future trials. 6. Reporting Transparency and Data Completeness Although formal tools such as the CONSORT or TIDieR checklists were not explicitly applied, reporting transparency and outcome completeness were critically evaluated during the full-text screening process. Incomplete reporting of outcome measures, statistical data, or intervention protocols led to the exclusion of several otherwise relevant studies from the meta-analysis. This emphasizes the importance of clear reporting standards in emerging areas of interventional research, particularly in non-pharmacological studies targeting neurocognitive outcomes. Future studies are encouraged to adopt standardized templates for intervention description and data availability to enhance replicability and integrative synthesis. 7. Neurocognitive Mechanisms of Action The neurocognitive mechanisms potentially underlying the observed improvements warrant further discussion. Table tennis is a highly integrative activity requiring rapid visuomotor coordination, continuous bilateral limb use, spatial attention, and anticipatory planning all of which are known to engage frontal and parietal cortical areas, basal ganglia circuits, and cerebellar pathways. Previous neuroimaging studies have demonstrated that motor-cognitive dual-task activities, such as table tennis, can enhance prefrontal activation and support neuroplasticity in older adults (Marusic et al., 2024). Additionally, recent evidence suggests that table tennis may preserve or restore functional connectivity patterns in key brain networks involved in attention and working memory (Peng et al., 2025). This aligns with the improvements observed in executive function, reactivity, and orientation reported across included studies. These findings offer a biologically plausible basis for interpreting the cognitive gains seen in both clinical and non-clinical aging populations and support further research into table tennis as a neurotherapeutic intervention. 8. Practical Implications and Application Potential From a translational perspective, the findings support the integration of table tennis into community-based and institutional care settings for older adults. Its accessibility, affordability, and engaging nature position it as a promising adjunct to conventional neurorehabilitation. In contrast to unidimensional exercise forms, table tennis provides simultaneous cognitive, motor, and social stimulation, which may improve adherence and long-term functional outcomes. Clinicians and policymakers may consider incorporating structured table tennis programs into preventive and therapeutic strategies targeting cognitive decline, especially given the low risk of adverse events and positive impact on quality of life domains such as autonomy and social engagement. Standardized intervention protocols, however, are necessary to maximize these benefits in clinical practice. 9. Conclusions This systematic review and meta-analysis provide compelling preliminary evidence supporting the cognitive, motor, and psychosocial benefits of table tennis interventions in individuals with neurodegenerative disorders and aging-related cognitive decline. The consistent improvements observed across global cognition, executive functioning, balance, and daily functioning underscore the multifactorial impact of this task-complex activity, which uniquely integrates aerobic exertion, visuomotor engagement, and strategic cognitive processing. Notably, the meta-analytical findings revealed large effect sizes across diverse clinical populations, reinforcing the therapeutic relevance of table tennis beyond recreational or leisure contexts. The results align with current neuroplasticity frameworks, suggesting that cognitively enriched physical activities can serve as non-pharmacological strategies to preserve or enhance brain function in vulnerable populations. Table tennis, by virtue of its high adaptability, bilateral demands, and inherent cognitive load, emerges as a viable and scalable modality within exercise-based cognitive intervention programs. Despite the overall strength of the evidence, future research should prioritize larger randomized controlled trials with standardized intervention protocols, long-term follow-up, and the inclusion of biomarker or neuroimaging endpoints to further elucidate underlying mechanisms and optimize clinical application. References 1. Hu, Q. (2014). A study on the functional improvement of Alzheimer’s disease patients through table tennis exercise combined with folic acid and vitamin B12 intervention [Master’s thesis]. 2. Hu, Q., & Wang, C. (2014). Clinical observation of table tennis to senile dementia. Shandong Sports Science & Technology , 36 (3), 45–47. 3. Huang, Y., Song, Y., Jiang, L., & Zhou, X. (2022). Leisure activities and the risk of dementia: A systematic review and meta-analysis of cohort studies. Nature Medicine , 28 (2), 239–248. https://doi.org/10.1038/s41591-021-01659-3 4. Inoue, K. (2020b). Table tennis exercise for patients with Parkinson disease: A prospective pilot study. 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Benefits of table tennis for brain health maintenance and prevention of dementia. Encyclopedia , 2 , 1577–1589. https://doi.org/10.3390/encyclopedia2030107 14. Youn, J., Kim, J., & Lee, S. (2021). Effects of combined exercise including table tennis on cognitive function in elderly individuals: A randomized controlled trial. Journal of Aging and Physical Activity , 29 (6), 1001–1010. https://doi.org/10.1123/japa.2020-0345 15. Zhou, L., Zhang, X., & Wang, R. (2020). Physical exercise improves cognitive function of older adults with mild cognitive impairment. Frontiers in Aging Neuroscience , 12 , 223. https://doi.org/10.3389/fnagi.2020.00223 Suplementary materials ***Table S1. Complete List of Screened Records in the Systematic Review Process (n = 499). This supplementary table includes all studies identified and screened during the systematic search across databases, regardless of inclusion status.*** Supplementary Material File (table 1. characteristics of included studies.docx) Download 14.80 KB File (table 2. cognitive function outcomes.docx) Download 14.28 KB File (table 3. motor function outcomes.docx) Download 14.25 KB File (table 4. quality of life measures.docx) Download 14.20 KB File (table 5. adverse events and exercise parameters.docx) Download 14.29 KB File (table 6. risk of bias assessment based on the jbi checklist.docx) Download 14.34 KB File (table 7. grade assessment for meta-analyzed outcomes.docx) Download 13.85 KB Information & Authors Information Version history V1 Version 1 21 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords cognitive rehabilitation exercise therapy meta-analysis neuroplasticity sensorimotor training Authors Affiliations Kinga Łosińska 0009-0009-0227-106X [email protected] Gdansk University of Physical Education and Sport Faculty of Physical Culture View all articles by this author Adam Maszczyk Gdansk University of Physical Education and Sport View all articles by this author Metrics & Citations Metrics Article Usage 1460 views 349 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Kinga Łosińska, Adam Maszczyk. The Impact of Table Tennis on Cognitive Health: A Systematic Review and Meta-Analysis of Its Effects on Alzheimer’s Disease, Parkinson’s Disease, and Dementia. Authorea . 21 June 2025. DOI: https://doi.org/10.22541/au.175047844.48110910/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); Cited by He Li, Hyunkyun Ahn, Minhye Shin, Table Tennis as a Sustainable Health Intervention: A Meta-Analysis of Its Effects on Balance and Cognitive Functions, Healthcare, 14 , 5, (675), (2026). https://doi.org/10.3390/healthcare14050675 Crossref Loading... View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. 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