Original research
The Active Ingredient of Cognitive Restoration: A Multicenter Randomized Controlled Trial of Sequential Combination of Aerobic Exercise and Computer-Based Cognitive Training in Stroke Survivors With Cognitive Decline

https://doi.org/10.1016/j.apmr.2018.12.020Get rights and content

Abstract

Objective

To investigate the efficacy of a sequential combination of aerobic exercise and cognitive training on cognitive function and other health-related outcomes in stroke survivors with cognitive decline.

Design

Intervention study and randomized controlled trial.

Setting

Hospital-based rehabilitation units.

Participants

Survivors of stroke with cognitive decline (N=30) were randomized to sequential combination training (SEQ) (n=15) or an active control (n=15) group.

Interventions

The SEQ group received 30 minutes of aerobic exercise, followed by 30 minutes of computerized cognitive training. The control group received 30 minutes of nonaerobic physical exercise, followed by 30 minutes of unstructured mental activities.

Main Outcome Measures

The primary outcome measure was cognitive function. Secondary outcome measures included physical function, social participation, and quality of life.

Results

Compared with the control group, the SEQ group had significantly improved Montreal Cognitive Assessment scores (P=.03) and Wechsler Memory Scale span scores (P=.012) after training. The endurance and mobility level measured by the 6-minute walk test (P=.25) was also enhanced in the SEQ group relative to the control group. However, the transfer of sequential training to social participation (Community Integration Questionnaire) and quality of life (EuroQoL questionnaire) was limited (P>.05 for both).

Conclusions

Aerobic exercise combined with computerized cognitive training has better effects on the cognitive functional status of survivors of stroke than an active control. The cognitive functional status of stroke survivors was better after participation in aerobic exercise combined with computerized training than after active control therapy, demonstrating the clinical significance of this combination therapy.

Section snippets

Eligibility criteria

Stroke survivors who met the following inclusion criteria were recruited: (1) ischemic or hemorrhagic stroke occurring at least 6 months before enrollment; (2) a Mini-Mental State Examination (MMSE) score of ≥19; (3) a Montreal Cognitive Assessment (MoCA) score of <26; (4) self-reported or informant-reported memory or cognitive complaints or score on the Clinical Dementia Rating scale ≤0.5; (5) able to follow the study instruction; (6) adequate cardiopulmonary function to perform aerobic

The SEQ group protocol

The participants in the SEQ group first underwent aerobic exercise training for 30 minutes, followed by 30 minutes of computer-based cognitive training at each session. The aerobic exercise training was conducted using a progressive resistance stationary bicycle as in the Quaney et al24 study. Participants performed 3 minutes of warm up, followed by 25 minutes of aerobic resistance exercise, and ended with 2 minutes of cool down for a total of 30 minutes. The target heart rate during the

Outcome measures

The outcomes were measured within 1 week before and after the intervention. The assessments were conducted by a trained and experienced therapist who was blinded to group allocation. The National Institutes of Health Stroke Scale, Fugl-Meyer Assessment, Modified Rankin Scale, and MMSE were measured to assess the disease severity of each participant at baseline.

Results

Thirty participants were randomly allocated to the 2 groups. The flow of participants through the study is presented in figure 1. Characteristics of those who enrolled in the study are presented in table 1. There were no statistically significant differences between groups by age, sex, and time poststroke, and by MMSE, MoCA, and the National Institutes of Health Stroke Scale scores (P>.05 for all).

The main findings of the results are illustrated in figure 2. The mean and SEM of the outcome

Discussion

To our knowledge, this study is the first randomized controlled trial to assess a sequential combination intervention of physical exercise and computerized cognitive training in stroke survivors with cognitive decline. Furthermore, we sought to extend previous work by investigating whether quality of life and social participation outcomes other than cognitive outcomes were improved after the combination training. We found that in patients with cognitive dysfunction poststroke, a 12- to 18-week

Conclusion

Poststroke cognitive rehabilitation has been identified as the top research priority for survivors of stroke.45 This finding adds greater urgency to the need to identify other active ingredients that optimize the design to maximize the generalization of training to social participation and health-related quality of life that is crucial for overall health status. This study determining the benefits of an additive active ingredient with sequential training suggests possible new avenues for

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    Supported by Chang Gung Memorial Hospital (grant no. CMRPD1E0281-0283, CMRPD1F0411-0413, CMRPG8E1001, BMRP553), Healthy Aging Research Center, Chang Gung University from the Featured Areas Research Center Program within the Framework of the Higher Education Sprout Project by the Ministry of Education (MOE) in Taiwan (grant no. EMRPD1H0451), and the Ministry of Science and Technology (grant no. MOST 105-2314-B-182A-011-MY3, MOST 106-2314-B-182-024-MY3) in Taiwan.

    Clinical Trial Registration No.: NCT03045991.

    Disclosures: none.

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