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1.  An Economic Evaluation of Resistance Training and Aerobic Training versus Balance and Toning Exercises in Older Adults with Mild Cognitive Impairment 
PLoS ONE  2013;8(5):e63031.
Mild cognitive impairment (MCI) represents a critical window to intervene against dementia. Exercise training is a promising intervention strategy, but the efficiency (i.e., relationship of costs and consequences) of such types of training remains unknown. Thus, we estimated the incremental cost-effectiveness of resistance training or aerobic training compared with balance and tone exercises in terms of changes in executive cognitive function among senior women with probable MCI.
Economic evaluation conducted concurrently with a six-month three arm randomized controlled trial including eighty-six community dwelling women aged 70 to 80 years living in Vancouver, Canada. Participants received twice-weekly resistance training (n = 28), twice weekly aerobic training (n = 30) or twice-weekly balance and tone (control group) classes (n = 28) for 6 months. The primary outcome measure of the Exercise for Cognition and Everyday Living (EXCEL) study assessed executive cognitive function, a test of selective attention and conflict resolution (i.e., Stroop Test). We collected healthcare resource utilization costs over six months.
Based on the bootstrapped estimates from our base case analysis, we found that both the aerobic training and resistance training interventions were less costly than twice weekly balance and tone classes. Compared with the balance and tone group, the resistance-training group had significantly improved performance on the Stroop Test (p = 0.04).
Resistance training and aerobic training result in health care cost saving and are more effective than balance and tone classes after only 6 months of intervention. Resistance training is a promising strategy to alter the trajectory of cognitive decline in seniors with MCI.
Trial Registration NCT00958867.
PMCID: PMC3653911  PMID: 23690976
2.  A Multi-State Model of Cognitive Dynamics in Relation to Resistance Training: The Contribution of Baseline Function 
Annals of epidemiology  2013;23(8):463-468.
We investigated: 1) the effect of different targeted exercise training on an individual’s overall probability for cognitive improvement, maintenance, or decline; and 2) the simultaneous effect of targeted exercise training and baseline function on the dynamics of executive functions using a multi-state transition model.
Analyses are based on a 12-month randomized clinical trial including 155 community-dwelling women 65 to 75 years old who were randomly allocated to once-weekly resistance training (1x RT; n=54), twice-weekly resistance training (2x RT; n=52), or twice-weekly balance and tone training (BAT; n=49). The primary outcome measure was performance on the Stroop Test, an executive cognitive test of selective attention and conflict resolution. Secondary outcomes of executive functions were set shifting and working memory.
Individuals in the 1x RT or 2x RT group demonstrated a significantly higher probability for improved performance on the Stroop Test (0.49; 95% CI=0.41 to 0.57) compared with those in the BAT group (0.25; 95% CI=0.25 to 0.40). Resistance training had significant effects on transitions in selective attention and conflict resolution.
Resistance training is efficacious in improving a measure of selective attention and conflict resolution in older women – probably more so among those with higher baseline cognitive function.
PMCID: PMC4476840  PMID: 23830936 CAMSID: cams4721
Resistance Training; Executive Functions; Multi-State Transition Model
3.  Change in Body Fat Mass Is Independently Associated with Executive Functions in Older Women: A Secondary Analysis of a 12-Month Randomized Controlled Trial 
PLoS ONE  2013;8(1):e52831.
To investigate the independent contribution of change in sub-total body fat and lean mass to cognitive performance, specifically the executive processes of selective attention and conflict resolution, in community-dwelling older women.
This secondary analysis included 114 women aged 65 to 75 years old. Participants were randomly allocated to once-weekly resistance training, twice-weekly resistance training, or twice-weekly balance and tone training. The primary outcome measure was the executive processes of selective attention and conflict resolution as assessed by the Stroop Test. Sub-total body fat and lean mass were measured by dual-energy x-ray absorptiometry (DXA) to determine the independent association of change in both sub-total body fat and sub-total body lean mass with Stroop Test performance at trial completion.
A multiple linear regression model showed reductions in sub-total body fat mass to be independently associated with better performance on the Stroop Test at trial completion after accounting for baseline Stroop performance, age, baseline global cognitive state, baseline number of comorbidities, baseline depression, and experimental group. The total variance explained was 39.5%; change in sub-total body fat mass explained 3.9% of the variance. Change in sub-total body lean mass was not independently associated with Stroop Test performance (P>0.05).
Our findings suggest that reductions in sub-total body fat mass – not sub-total lean mass – is associated with better performance of selective attention and conflict resolution.
PMCID: PMC3538688  PMID: 23308123
4.  Economic evaluation of dose-response resistance training in older women: a cost effectiveness and cost utility analysis 
To estimate the incremental cost effectiveness and cost utility of a once weekly or twice weekly resistance training intervention compared with twice weekly balance and tone classes in terms of falls prevented and quality adjusted life years (QALYs) gained.
Economic evaluation conducted concurrently with a three arm randomised controlled trial including one hundred and fifty-five community dwelling women aged 65 to 75 years, Mini Mental State Examination ≥24, and visual acuity 20/40 or better. Participants received the once weekly resistance training (n=54), the twice weekly resistance training (n=51) or the twice weekly balance and tone (the comparator) classes (n=50) for one year. Measurements included number of falls for each participant, healthcare resource utilization and associated costs over nine months; health status was assessed using the EQ-5D and SF-6D to calculate QALYs.
Based on the point estimates from our base case analysis, we found that both once and twice weekly resistance training was less costly (p<0.05) and more effective than twice weekly balance and tone classes. The incremental QALYs assessed using the SF-6D were 0.003 for both the once and twice weekly resistance training groups, compared with the twice weekly balance and tone classes. The incremental QALYs assessed using the EQ-5D were 0.084 for the once and 0.179 twice weekly resistance training groups, respectively compared with the twice weekly balance and tone classes.
An individually tailored resistance training intervention delivered once or twice weekly provided better value for money for falls prevention than balance and tone classes.
PMCID: PMC4508130  PMID: 20683707 CAMSID: cams4892
falls; cost-effectiveness; cost-utility; economic evaluation; resistance training; older adults
5.  Sustained economic benefits of resistance training among community-dwelling senior women 
Previously, we demonstrated that 12 months of group based resistance training intervention delivered once or twice weekly provided significantly lower healthcare resource utilization costs and health benefits including improvement in health related quality of life than balance and tone exercises.
We conducted a 12-month follow-up study to determine whether these health and cost benefits of resistance training were sustained 12 months after formal cessation of the intervention.
Cost-utility analysis conducted alongside a randomized controlled trial.
Community-dwelling women aged 65 to 75 years living in Vancouver, British Columbia.
123 of the 155 community-dwelling women aged 65 to 75 years who originally were randomly allocated to once-weekly resistance training (n=54), twice-weekly resistance training (n=52), or to twice-weekly balance and tone exercises (i.e., control group) (n=49) participated in the 12-month follow-up study. Of these, 98 took part in the economic evaluation (twice-weekly balance and tone exercises, n=28, once-weekly resistance training, n=35; twice-weekly resistance training, n=35).
Our primary outcome measure was incremental cost per quality adjusted life year (QALY) gained. Healthcare resource utilization was assessed over 21 months (2009 prices); health status was assessed using the EQ-5D to calculate QALYs using a 21 month time horizon.
Once- and twice-weekly resistance training were less costly than balance and tone classes with incremental mean healthcare costs of Canadian dollars (CAD$) -$1857 and -$1077, respectively. The incremental QALYs for once- and twice weekly resistance training were -0.051 and -0.081, respectively, compared with balance and tone exercises.
The cost benefits of participating in a 12-month resistance training intervention were sustained for both the once- and twice-weekly resistance training group while the health benefits were not.
PMCID: PMC4019577  PMID: 21718265 CAMSID: cams2567
quality adjusted life year; executive functions; cognition; older adults; cost-utility analysis
6.  SF-6D and EQ-5D result in widely divergent incremental cost effectiveness ratios in a clinical trial of older women: Implications for health policy decisions 
Two major challenges facing decision makers within our health care system if the choice between alternative and new interventions for the same clinical indication or diagnosis. To guide such choices, economic evaluations that provide evidence of the costs and effects are increasingly prevalent. Very few studies have compared impact of different preference based utility instruments and the resultant incremental cost-effectiveness ratio on decision-making in population specific settings. We compared the incremental cost-effectiveness ratios, in a clinical trial of older women, estimated using the EuroQol-5D (EQ-5D) and the Short Form-6D (SF-6D) to discuss the implications on decision making.
Using both the EQ-5D and the SF-6D, we compared the incremental cost per quality-adjusted life year (QALY) gained in a clinical trial in older women. The trial consisted of two parts, a 12-month randomized controlled trial with a 12-month following was conducted among 155 community-dwelling women aged 65 to 75 years. For the followup study, 123 of the 155 who originally were randomly allocated to once-weekly resistance training (n=54), twice-weekly resistance training (n=52), or to twice-weekly balance and tone exercises (i.e., control group) (n=49) participated in the 12-month follow-up study. For the intervention period, 155 individuals are included in the economic evaluation. For the followup study, 98 took part in the economic evaluation (twice-weekly balance and tone exercises, n=28, once-weekly resistance training, n=35; twice-weekly resistance training, n=35). Our primary outcome measure was incremental cost per quality adjusted life year (QALY) gained. Healthcare resource utilization was assessed over 21 months (2009 prices); health status was assessed using the EQ-5D and SF-6D to calculate QALYs using a 21 month time horizon.
At cessation of the 12-month intervention, the incremental QALYs were 0.084 (EQ-5D) and 0.003 (SF-6D) for the once and 0.179 (EQ-5D) and 0.003 (SF-6D) twice weekly resistance training groups, compared with the twice weekly balance and tone classes. At cessation of the 12-month followup, the incremental QALY was −0.051 (EQ-5D) and −0.144 (SF-6D) for the once-weekly resistance training group and −0.081 (EQ-5D) and −0.127 (SF-6D) for the twice-weekly resistance training group compared with balance and tone classes
The choice of EQ-5D or SF-6D matters, when used to estimate QALYs for the incremental cost effectiveness ratio to inform decisions. We found the incremental QALYs estimated from the EQ-5D were threefold greater than those estimated from the SF-6D. Hence, the choice of preference based utility instrument holds the potential to substantially impact the decision to fund a new health care technology.
PMCID: PMC4508131  PMID: 21909728 CAMSID: cams4893
health related quality of life; older adults; cost utility analysis; incremental cost-effectiveness ratio
7.  Changes in executive functions and self-efficacy are independently associated with improved usual gait speed in older women 
BMC Geriatrics  2010;10:25.
Improved usual gait speed predicts substantial reduction in mortality. A better understanding of the modifiable factors that are independently associated with improved gait speed would ensure that intervention strategies are developed based on a valid theoretical framework. Thus, we examined the independent association of change in executive functions and change in falls-related self-efficacy with improved gait speed among community-dwelling senior women.
A secondary analysis of the 135 senior women aged 65 to 75 years old who completed a 12-month randomized controlled trial of resistance training. Usual gait speed was assessed using a 4-meter walk. Three executive processes were assessed by standard neuropsychological tests: 1) set shifting; 2) working memory; and 3) selective attention and response inhibition. A linear regression model was constructed to determine the independent association of change in executive functions and falls-related self-efficacy with change in gait speed.
Improved selective attention and conflict resolution, and falls-related self-efficacy, were independently associated with improved gait speed after accounting for age, global cognition, baseline gait speed, and change in quadriceps strength. The total variance explained was 24%.
Interventions that target executive functions and falls-related self-efficacy, in addition to physical functions, to improve gait speed may be more efficacious than those that do not.
Trial Registration Identifier: NCT00426881
PMCID: PMC2887871  PMID: 20482830
8.  The Effect of Intermittent Antenatal Iron Supplementation on Maternal and Infant Outcomes in Rural Viet Nam: A Cluster Randomised Trial 
PLoS Medicine  2013;10(6):e1001470.
Beverley-Anne Biggs and colleagues conduct a community-based cluster randomized trial in rural Viet Nam to compare the effect of antenatal iron-folic acid supplementation taken daily or twice weekly on maternal and infant outcomes.
Please see later in the article for the Editors' Summary
Anemia affects over 500 million women, and in pregnancy is associated with impaired maternal and infant outcomes. Intermittent antenatal iron supplementation is an attractive alternative to daily dosing; however, the impact of this strategy on infant outcomes remains unclear. We compared the effect of intermittent antenatal iron supplementation with daily iron supplementation on maternal and infant outcomes in rural Viet Nam.
Methods and Findings
This cluster randomised trial was conducted in Ha Nam province, Viet Nam. 1,258 pregnant women (<16 wk gestation) in 104 communes were assigned to daily iron–folic acid (IFA), twice weekly IFA, or twice weekly multiple micronutrient (MMN) supplementation. Primary outcome was birth weight. Mean birth weight was 3,148 g (standard deviation 416). There was no difference in the birth weights of infants of women receiving twice weekly IFA compared to daily IFA (mean difference [MD] 28 g; 95% CI −22 to 78), or twice weekly MMN compared to daily IFA (MD −36.8 g; 95% CI −82 to 8.2). At 32 wk gestation, maternal ferritin was lower in women receiving twice weekly IFA compared to daily IFA (geometric mean ratio 0.73; 95% CI 0.67 to 0.80), and in women receiving twice weekly MMN compared to daily IFA (geometric mean ratio 0.62; 95% CI 0.57 to 0.68), but there was no difference in hemoglobin levels. Infants of mothers who received twice weekly IFA had higher cognitive scores at 6 mo of age compared to those who received daily IFA (MD 1.89; 95% CI 0.23 to 3.56).
Twice weekly antenatal IFA or MMN did not produce a clinically important difference in birth weight, when compared to daily IFA supplementation. The significant improvement in infant cognitive outcomes at 6 mo of age following twice weekly antenatal IFA requires further exploration, and provides additional support for the use of intermittent, rather than daily, antenatal IFA in populations with low rates of iron deficiency.
Trial registration
Australia New Zealand Clinical Trials Registry 12610000944033
Please see later in the article for the Editors' Summary
Editors' Summary
Anemia is a common condition in which the blood does not supply the body with enough oxygen because of a low number of red blood cells or low levels of hemoglobin—the iron-containing pigment that enables red blood cells to carry oxygen. Iron deficiency is the most common cause of anemia worldwide and, according to the World Health Organization, affects over 2 billion people: half of all pregnant women and 40% of preschool children in low- and middle-income countries are thought to be anemic. Anemia contributes to 20% of all maternal deaths and is also linked to increased maternal morbidity, higher rates of preterm birth and low birth weight, and reduced infant survival, with potential long-term consequences for child growth and development. Identifying and treating iron deficiency anemia is therefore a global health priority.
Why Was This Study Done?
Daily iron–folic acid supplementation given from early in pregnancy is the standard recommended approach to prevent and treat anemia in pregnant women, but recently the World Health Organization recommended intermittent use because of poor compliance with daily regimes (because of side effects) and poor bowel absorption. However, the evidence from many of the studies used to support this recommendation was of poor quality, and so it remains unclear whether intermittent supplementation is as, or more, effective than daily supplementation, especially in lower income settings where antenatal testing for anemia is not readily available. So in this study, the researchers conducted a community-based cluster randomized trial (where groups of people are randomized, rather than individuals) in rural Viet Nam to compare the effect of antenatal iron–folic acid supplementation taken twice weekly (either alone, or in combination with other micronutrients) with daily iron–folic acid supplementation, on maternal and infant outcomes during the first six months of life.
What Did the Researchers Do and Find?
The researchers randomized 104 communes in Ha Nam Province, Viet Nam, and enrolled 1,258 women who were less than 16 weeks pregnant into the study between September and November 2010. Although the researchers intended to register the trial before the study started, registration was delayed by a month because the supplements arrived earlier than the researchers anticipated, and they thought it best to start recruiting at that time to avoid the Vietnamese New Year, when women might be travelling. Each woman was interviewed and had blood taken for hemoglobin and iron indices (ferritin) before receiving daily iron–folic acid supplementation (426 women), twice weekly iron–folic acid supplementation (425 women), or twice weekly iron–folic acid supplementation plus micronutrients (407 women). The women had follow-up assessments at 32 weeks gestation, delivery, and at six months postpartum: their infants were assessed at birth and at six months old.
The researchers found that at enrollment, the women's average hemoglobin concentration was 123 g/l, and 12.6% of the women were anemic. At 32 weeks gestation, 10.8% of the women were anemic, but there was no difference in hemoglobin levels between the three supplement groups. The average ferritin level was 75.6 µg/l at enrollment, with 2.2% of women iron deficient. Ferritin levels decreased from enrollment to 32 weeks gestation in all supplement groups but were lower in women who took twice weekly supplements. The researchers also found that birth weight (the primary outcome) was similar in all supplement groups, and there were also no differences in gestational age or in the risk of prematurity, stillbirth, or early neonatal death. At six months, there were also no differences in the levels of infant hemoglobin, prevalence of anemia, or growth rates. However, infants born to mothers in the twice weekly iron–folic acid group had improved cognitive development compared to infants born to mothers in the daily supplement group. Finally, the researchers found that adherence rates were significantly higher in the twice weekly iron–folic acid supplement group compared to the once daily regime.
What Do These Findings Mean?
These findings suggest that in an area of Southeast Asia with low anemia prevalence, once daily antenatal supplementation with iron–folic acid did not provide any benefits in birth weight or improved infant growth over twice weekly supplementation. Furthermore, twice weekly supplementation with iron–folic acid was associated with improved maternal adherence rates and also improved cognitive development in infants aged six months—a finding that requires further study and provides added support for the use of intermittent iron–folic acid supplementation over daily supplementation.
Additional Information
Please access these websites via the online version of this summary at
The World Health Organization website has comprehensive information on anemia, including a report of global estimates and the guideline Intermittent Iron and Folic Acid Supplementation in Non-Anaemic Pregnant Women
Wikipedia provides information on iron supplementation (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
PMCID: PMC3708703  PMID: 23853552
9.  Study protocol: a randomised controlled trial of the effects of a multi-modal exercise program on cognition and physical functioning in older women 
BMC Geriatrics  2012;12:60.
Intervention studies testing the efficacy of cardiorespiratory exercise have shown some promise in terms of improving cognitive function in later life. Recent developments suggest that a multi-modal exercise intervention that includes motor as well as physical training and requires sustained attention and concentration, may better elicit the actual potency of exercise to enhance cognitive performance. This study will test the effect of a multi-modal exercise program, for older women, on cognitive and physical functioning.
This randomised controlled trial involves community dwelling women, without cognitive impairment, aged 65–75 years. Participants are randomised to exercise intervention or non-exercise control groups, for 16 weeks. The intervention consists of twice weekly, 60 minute, exercise classes incorporating aerobic, strength, balance, flexibility, co-ordination and agility training. Primary outcomes are measures of cognitive function and secondary outcomes include physical functioning and a neurocognitive biomarker (brain derived neurotrophic factor). Measures are taken at baseline and 16 weeks later and qualitative data related to the experience and acceptability of the program are collected from a sub-sample of the intervention group.
If this randomised controlled trial demonstrates that multimodal exercise (that includes motor fitness training) can improve cognitive performance in later life, the benefits will be two-fold. First, an inexpensive, effective strategy will have been developed that could ameliorate the increased prevalence of age-related cognitive impairment predicted to accompany population ageing. Second, more robust evidence will have been provided about the mechanisms that link exercise to cognitive improvement allowing future research to be better focused and potentially more productive.
Trial registration
Australian and New Zealand Clinical Trial Registration Number: ANZCTR12612000451808
PMCID: PMC3503610  PMID: 23009189
Exercise; Cognition; Aged; Multi-modal exercise; Brain derived neurotrophic factor
10.  Strength-balance supplemented with computerized cognitive training to improve dual task gait and divided attention in older adults: a multicenter randomized-controlled trial 
BMC Geriatrics  2014;14:134.
Exercise interventions often do not combine physical and cognitive training. However, this combination is assumed to be more beneficial in improving walking and cognitive functioning compared to isolated cognitive or physical training.
A multicenter parallel randomized controlled trial was conducted to compare a motor to a cognitive-motor exercise program. A total of 182 eligible residents of homes-for-the-aged (n = 159) or elderly living in the vicinity of the homes (n = 23) were randomly assigned to either strength-balance (SB) or strength-balance-cognitive (SBC) training. Both groups conducted similar strength-balance training during 12 weeks. SBC additionally absolved computerized cognitive training. Outcomes were dual task costs of walking, physical performance, simple reaction time, executive functions, divided attention, fear of falling and fall rate. Participants were analysed with an intention to treat approach.
The 182 participants (mean age ± SD: 81.5 ± 7.3 years) were allocated to either SB (n = 98) or SBC (n = 84). The attrition rate was 14.3%. Interaction effects were observed for dual task costs of step length (preferred walking speed: F(1,174) = 4.94, p = 0.028, η2 = 0.027, fast walking speed: F(1,166) = 6.14, p = 0.009, η2 = 0.040) and dual task costs of the standard deviation of step length (F(1,166) = 6.14, p = 0.014, η2 = 0.036), in favor of SBC. Significant interactions in favor of SBC revealed for in gait initiation (F(1,166) = 9.16, p = 0.003, η2 = 0.052), ‘reaction time’ (F(1,180) = 5.243, p = 0.023, η2 = 0.028) & ‘missed answers’ (F(1,180) = 11.839, p = 0.001, η2 = 0.062) as part of the test for divided attention. Within-group comparison revealed significant improvements in dual task costs of walking (preferred speed; velocity (p = 0.002), step time (p = 0.018), step length (p = 0.028), fast speed; velocity (p < 0.001), step time (p = 0.035), step length (p = 0.001)), simple reaction time (p < 0.001), executive functioning (Trail making test B; p < 0.001), divided attention (p < 0.001), fear of falling (p < 0.001), and fall rate (p < 0.001).
Combining strength-balance training with specific cognitive training has a positive additional effect on dual task costs of walking, gait initiation, and divided attention. The findings further confirm previous research showing that strength-balance training improves executive functions and reduces falls.
Trial registration
This trial has been registered under ISRCTN75134517
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2318-14-134) contains supplementary material, which is available to authorized users.
PMCID: PMC4293005  PMID: 25511081
Cognitive-motor training; Dual task costs; Divided attention; Cognitive functions; Executive functions; Exercise; Fall prevention
11.  Functional neural correlates of reduced physiological falls risk 
It is currently unclear whether the function of brain regions associated with executive cognitive processing are independently associated with reduced physiological falls risk. If these are related, it would suggest that the development of interventions targeted at improving executive neurocognitive function would be an effective new approach for reducing physiological falls risk in seniors.
We performed a secondary analysis of 73 community-dwelling senior women aged 65 to 75 years old who participated in a 12-month randomized controlled trial of resistance training. Functional MRI data were acquired while participants performed a modified Eriksen Flanker Task - a task of selective attention and conflict resolution. Brain volumes were obtained using MRI. Falls risk was assessed using the Physiological Profile Assessment (PPA).
After accounting for baseline age, experimental group, baseline PPA score, and total baseline white matter brain volume, baseline activation in the left frontal orbital cortex extending towards the insula was negatively associated with reduced physiological falls risk over the 12-month period. In contrast, baseline activation in the paracingulate gyrus extending towards the anterior cingulate gyrus was positively associated with reduced physiological falls risk.
Baseline activation levels of brain regions underlying response inhibition and selective attention were independently associated with reduced physiological falls risk. This suggests that falls prevention strategies may be facilitated by incorporating intervention components - such as aerobic exercise - that are specifically designed to induce neurocognitive plasticity.
Trial Registration Identifier: NCT00426881
PMCID: PMC3178476  PMID: 21846395
12.  Aerobic Exercise Increases Hippocampal Volume in Older Women with Probable Mild Cognitive Impairment: A 6-Month Randomized Controlled Trial 
Mild cognitive impairment (MCI) is a well-recognized risk factor for dementia and represents a vital opportunity for intervening. Exercise is a promising strategy for combating cognitive decline, by improving both brain structure and function. Specifically, aerobic training (AT) improved spatial memory and hippocampal volume in healthy community-dwelling older adults. In older women with probable MCI, we previously demonstrated that both resistance training (RT) and AT improved memory. In this secondary analysis, we investigated: 1) the effect of both RT and AT on hippocampal volume; and 2) the association between change in hippocampal volume and change in memory.
Eighty-six females aged 70 to 80 years with probable MCI were randomly assigned to a six-month, twice-weekly program of: 1) AT, 2) RT, or 3) Balance and Tone Training (BAT; i.e., control). At baseline and trial completion, participants performed a 3T magnetic resonance imaging scan to determine hippocampal volume. Verbal memory and learning was assessed by Rey’s Auditory Verbal Learning Test.
Compared with the BAT group, AT significantly improved left, right, and total hippocampal volumes (p≤0.03). After accounting for baseline cognitive function and experimental group, increased left hippocampal volume was independently associated with reduced verbal memory and learning performance as indexed by loss after interference (r=0.42, p=0.03).
Aerobic training significantly increased hippocampal volume in older women with probable MCI. More research is needed to ascertain the relevance of exercise-induced changes in hippocampal volume on memory performance in older adults with MCI.
PMCID: PMC4508129  PMID: 24711660 CAMSID: cams4891
Mild cognitive impairment; aerobic exercise; memory; hippocampus; brain volume
13.  Enhancing cognitive functioning in the elderly: multicomponent vs resistance training 
The primary purpose of this study was to compare the effects of two different exercise training programs on executive cognitive functions and functional mobility in older adults. A secondary purpose was to explore the potential mediators of training effects on executive function and functional mobility with particular reference to physical fitness gains.
A sample of 42 healthy community dwelling adults aged 65 to 75 years participated twice weekly for 3 months in either: (1) multicomponent training, prioritizing neuromuscular coordination, balance, agility, and cognitive executive control; or (2) progressive resistance training for strength conditioning. Participants were tested at baseline (T1), following a 4-week control period (T2), and finally at postintervention (T3) for executive function (inhibition and cognitive flexibility) and functional mobility (maximal walking speed with and without additional task requirements). Cardiorespiratory and muscular fitness were also assessed as potential mediators.
Indices of inhibition, the functions involved in the deliberate withholding of prepotent or automatic responses, and measures of functional mobility improved after the intervention, independent of training type. Mediation analysis suggested that different mechanisms underlie the effects of multicomponent and progressive resistance training. While multicomponent training seemed to directly affect inhibitory capacity, resistance training seemed to affect it indirectly through gains in muscular strength. Physical fitness and executive function variables did not mediate functional mobility changes.
These results confirm that physical training benefits executive function and suggest that different training types might lead to such benefits through different pathways. Both types of training also promoted functional mobility in older adulthood; however, neither inhibitory capacity, nor muscular strength gains seemed to explain functional mobility outcomes.
PMCID: PMC3546758  PMID: 23341738
executive function; functional mobility; physical training; physical fitness; aging
14.  The gait and balance of patients with diabetes can be improved: a randomised controlled trial 
Diabetologia  2009;53(3):458-466.
Gait characteristics and balance are altered in diabetic patients. Little is known about possible treatment strategies. This study evaluates the effect of a specific training programme on gait and balance of diabetic patients.
This was a randomised controlled trial (n = 71) with an intervention (n = 35) and control group (n = 36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up.
The trial is closed to recruitment and follow-up. After training, the intervention group increased habitual walking speed by 0.149 m/s (p < 0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength. Two patients developed pain in their Achilles tendon: the progression for two related exercises was slowed down.
Specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients. Further studies are needed to explore the influence of these improvements on the number of reported falls, patients’ physical activity levels and quality of life.
Trial registration: NCT00637546
This work was supported by the Swiss National Foundation (SNF): PBSKP-123446/1/
Electronic supplementary material
The online version of this article (doi:10.1007/s00125-009-1592-4) contains supplementary material, which is available to authorised users.
PMCID: PMC2815802  PMID: 19921145
Balance; Clinical diabetes; Diabetic foot; Exercise; Fear; Gait disorders; Joint mobility; Neuropathy; Muscle strength; Walking
15.  Computerized Cognitive Training in Cognitively Healthy Older Adults: A Systematic Review and Meta-Analysis of Effect Modifiers 
PLoS Medicine  2014;11(11):e1001756.
Michael Valenzuela and colleagues systematically review and meta-analyze the evidence that computerized cognitive training improves cognitive skills in older adults with normal cognition.
Please see later in the article for the Editors' Summary
New effective interventions to attenuate age-related cognitive decline are a global priority. Computerized cognitive training (CCT) is believed to be safe and can be inexpensive, but neither its efficacy in enhancing cognitive performance in healthy older adults nor the impact of design factors on such efficacy has been systematically analyzed. Our aim therefore was to quantitatively assess whether CCT programs can enhance cognition in healthy older adults, discriminate responsive from nonresponsive cognitive domains, and identify the most salient design factors.
Methods and Findings
We systematically searched Medline, Embase, and PsycINFO for relevant studies from the databases' inception to 9 July 2014. Eligible studies were randomized controlled trials investigating the effects of ≥4 h of CCT on performance in neuropsychological tests in older adults without dementia or other cognitive impairment. Fifty-two studies encompassing 4,885 participants were eligible. Intervention designs varied considerably, but after removal of one outlier, heterogeneity across studies was small (I2 = 29.92%). There was no systematic evidence of publication bias. The overall effect size (Hedges' g, random effects model) for CCT versus control was small and statistically significant, g = 0.22 (95% CI 0.15 to 0.29). Small to moderate effect sizes were found for nonverbal memory, g = 0.24 (95% CI 0.09 to 0.38); verbal memory, g = 0.08 (95% CI 0.01 to 0.15); working memory (WM), g = 0.22 (95% CI 0.09 to 0.35); processing speed, g = 0.31 (95% CI 0.11 to 0.50); and visuospatial skills, g = 0.30 (95% CI 0.07 to 0.54). No significant effects were found for executive functions and attention. Moderator analyses revealed that home-based administration was ineffective compared to group-based training, and that more than three training sessions per week was ineffective versus three or fewer. There was no evidence for the effectiveness of WM training, and only weak evidence for sessions less than 30 min. These results are limited to healthy older adults, and do not address the durability of training effects.
CCT is modestly effective at improving cognitive performance in healthy older adults, but efficacy varies across cognitive domains and is largely determined by design choices. Unsupervised at-home training and training more than three times per week are specifically ineffective. Further research is required to enhance efficacy of the intervention.
Please see later in the article for the Editors' Summary
Editors' Summary
As we get older, we notice many bodily changes. Our hair goes grey, we develop new aches and pains, and getting out of bed in the morning takes longer than it did when we were young. Our brain may also show signs of aging. It may take us longer to learn new information, we may lose our keys more frequently, and we may forget people's names. Cognitive decline—developing worsened thinking, language, memory, understanding, and judgment—can be a normal part of aging, but it can also be an early sign of dementia, a group of brain disorders characterized by a severe, irreversible decline in cognitive functions. We know that age-related physical decline can be attenuated by keeping physically active; similarly, engaging in activities that stimulate the brain throughout life is thought to enhance cognition in later life and reduce the risk of age-related cognitive decline and dementia. Thus, having an active social life and doing challenging activities that stimulate both the brain and the body may help to stave off cognitive decline.
Why Was This Study Done?
“Brain training” may be another way of keeping mentally fit. The sale of computerized cognitive training (CCT) packages, which provide standardized, cognitively challenging tasks designed to “exercise” various cognitive functions, is a lucrative and expanding business. But does CCT work? Given the rising global incidence of dementia, effective interventions that attenuate age-related cognitive decline are urgently needed. However, the impact of CCT on cognitive performance in older adults is unclear, and little is known about what makes a good CCT package. In this systematic review and meta-analysis, the researchers assess whether CCT programs improve cognitive test performance in cognitively healthy older adults and identify the aspects of cognition (cognitive domains) that are responsive to CCT, and the CCT design features that are most important in improving cognitive performance. A systematic review uses pre-defined criteria to identify all the research on a given topic; meta-analysis uses statistical methods to combine the results of several studies.
What Did the Researchers Do and Find?
The researchers identified 51 trials that investigated the effects of more than four hours of CCT on nearly 5,000 cognitively healthy older adults by measuring several cognitive functions before and after CCT. Meta-analysis of these studies indicated that the overall effect size for CCT (compared to control individuals who did not participate in CCT) was small but statistically significant. An effect size quantifies the difference between two groups; a statistically significant result is a result that is unlikely to have occurred by chance. So, the meta-analysis suggests that CCT slightly increased overall cognitive function. Notably, CCT also had small to moderate significant effects on individual cognitive functions. For example, some CCT slightly improved nonverbal memory (the ability to remember visual images) and working memory (the ability to remember recent events; short-term memory). However, CCT had no significant effect on executive functions (cognitive processes involved in planning and judgment) or attention (selective concentration on one aspect of the environment). The design of CCT used in the different studies varied considerably, and “moderator” analyses revealed that home-based CCT was not effective, whereas center-based CCT was effective, and that training sessions undertaken more than three times a week were not effective. There was also some weak evidence suggesting that CCT sessions lasting less than 30 minutes may be ineffective. Finally, there was no evidence for the effectiveness of working memory training by itself (for example, programs that ask individuals to recall series of letters).
What Do These Findings Mean?
These findings suggest that CCT produces small improvements in cognitive performance in cognitively healthy older adults but that the efficacy of CCT varies across cognitive domains and is largely determined by design aspects of CCT. The most important result was that “do-it-yourself” CCT at home did not produce improvements. Rather, the small improvements seen were in individuals supervised by a trainer in a center and undergoing sessions 1–3 times a week. Because only cognitively healthy older adults were enrolled in the studies considered in this systematic review and meta-analysis, these findings do not necessarily apply to cognitively impaired individuals. Moreover, because all the included studies measured cognitive function immediately after CCT, these findings provide no information about the durability of the effects of CCT or about how the effects of CCT on cognitive function translate into real-life outcomes for individuals such as independence and the long-term risk of dementia. The researchers call, therefore, for additional research into CCT, an intervention that might help to attenuate age-related cognitive decline and improve the quality of life for older individuals.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Druin Burch
The US National Institute on Aging provides information for patients and carers about age-related forgetfulness, about memory and cognitive health, and about dementia (in English and Spanish)
The UK National Health Service Choices website also provides information about dementia and about memory loss
MedlinePlus provides links to additional resources about memory, mild cognitive impairment, and dementia (in English and Spanish)
PMCID: PMC4236015  PMID: 25405755
16.  Exercise Training and Recreational Activities to Promote Executive Functions in Chronic Stroke: A Proof-of-Concept Study 
Stroke survivors represent a target population in need of intervention strategies to promote cognitive function and prevent dementia. Both exercise and recreational activities are promising strategies. We assessed the effect of a six-month exercise and recreation program on executive functions in adults with chronic stroke.
A six-month ancillary study within a multi-centre randomized trial. Twenty-eight chronic stroke survivors (i.e., ≥ 12 months since an index stroke) were randomized to one of two experimental groups: intervention (INT; n=12) or delayed intervention (D-INT; n=16). Participants of the INT group received a six-month community-based structured program that included two sessions of exercise training and one session of recreation and leisure activities per week. Participants of the D-INT group received usual care. The primary outcome measure was the Stroop Test, a cognitive test of selective attention and conflict resolution. Secondary cognitive measures included set shifting and working memory. Mood, functional capacity, and general balance and mobility were additional secondary outcome measures.
Compared with the D-INT group, the INT group significantly improved selective attention and conflict resolution (p=0.02), working memory (p=0.04), and functional capacity (p=0.02) at the end of the six-month intervention period. Improved selective attention and conflict resolution was significantly associated with functional capacity at six months (r=0.39; p=0.04).
This is the first randomized study to demonstrate that an exercise and recreation program can significantly benefit executive functions in community-dwelling chronic stroke survivors who are mildly cognitively impaired – a population at high-risk for dementia and functional decline. Thus, clinicians should consider prescribing exercise and recreational activities in the cognitive rehabilitation of chronic stroke survivors.
Clinical Trial Registration Unique identifier: NCT01085240.
PMCID: PMC4486380  PMID: 25440324 CAMSID: cams4837
Exercise; Socialization; Executive Functions; Chronic Stroke
17.  A Randomized Trial to Measure the Impact of a Community-Based Cognitive Training Intervention on Balance and Gait in Cognitively Intact Black Older Adults 
Fall prevention is important for maintaining mobility and independence into old age. Approaches for reducing falls include exercise, tai chi, and home modifications; however, causes of falling are multifactorial and include not just physical but cognitive factors. Cognitive decline occurs with age, but older adults with the greatest declines in executive function experience more falls. The purpose of this study was twofold: to demonstrate the feasibility of a community-based cognitive training program for cognitively intact Black older adults and to analyze its impact on gait and balance in this population.
This pilot study used a pretest/posttest randomized trial design with assignment to an intervention or control group. Participants assigned to the intervention completed a computer-based cognitive training class that met 2 days a week for 60 min over 10 weeks. Classes were held at senior/community centers. Primary outcomes included balance as measured by the Berg Balance Scale (BBS), 10-meter gait speed, and 10-meter gait speed under visuospatial dual-task condition. All measures were assessed at baseline and immediately post-intervention.
Participants were community-dwelling Black adults with a mean age of 72.5 and history of falls (N = 45). Compared to controls, intervention participants experienced statistically significant improvements in BBS and gait speed. Mean performance on distracted gait speed also improved more for intervention participants compared to controls.
Findings from this pilot randomized trial demonstrate the feasibility of a community-based cognitive training intervention. They provide initial evidence that cognitive training may be an efficacious approach toward improving balance and gait in older adults known to have a history of falls.
PMCID: PMC4326003  PMID: 25274713
aging and health; community health; computer-mediated health promotion; health behavior new media and social media interventions
18.  Protocol for a randomized comparison of integrated versus consecutive dual task practice in Parkinson’s disease: the DUALITY trial 
BMC Neurology  2014;14:61.
Multiple tasking is an integral part of daily mobility. Patients with Parkinson’s disease have dual tasking difficulties due to their combined motor and cognitive deficits. Two contrasting physiotherapy interventions have been proposed to alleviate dual tasking difficulties: either to discourage simultaneous execution of dual tasks (consecutive training); or to practice their concurrent use (integrated training). It is currently unclear which of these training methods should be adopted to achieve safe and consolidated dual task performance in daily life. Therefore, the proposed randomized controlled trial will compare the effects of integrated versus consecutive training of dual tasking (tested by combining walking with cognitive exercises).
Methods and design
Hundred and twenty patients with Parkinson’s disease will be recruited to participate in this multi-centered, single blind, randomized controlled trial. Patients in Hoehn & Yahr stage II-III, with or without freezing of gait, and who report dual task difficulties will be included. All patients will undergo a six-week control period without intervention after which they will be randomized to integrated or consecutive task practice. Training will consist of standardized walking and cognitive exercises delivered at home four times a week during six weeks. Treatment is guided by a physiotherapist twice a week and consists of two sessions of self-practice using an MP3 player. Blinded testers will assess patients before and after the control period, after the intervention period and after a 12-week follow-up period. The primary outcome measure is dual task gait velocity, i.e. walking combined with a novel untrained cognitive task to evaluate the consolidation of learning. Secondary outcomes include several single and dual task gait and cognitive measures, functional outcomes and a quality of life scale. Falling will be recorded as a possible adverse event using a weekly phone call for the entire study period.
This randomized study will evaluate the effectiveness and safety of integrated versus consecutive task training in patients with Parkinson’s disease. The study will also highlight whether dual task gait training leads to robust motor learning effects, and whether these can be retained and carried-over to untrained dual tasks and functional mobility.
Trial registration NCT01375413.
PMCID: PMC3974198  PMID: 24674594
Parkinson disease; Rehabilitation; Physical therapy; Neurologic gait disorder; Cognition; Dual task
19.  Positive effects of resistance training in frail elderly patients with dementia after long-term physical restraint 
Age  2013;36(2):801-811.
This study investigated the effects of a multicomponent exercise intervention on muscle strength, incidence of falls and functional outcomes in frail elderly patients with dementia after long-term physical restraint, followed by 24 weeks of training cessation. Eighteen frail elderly patients with mild dementia (88.1 ± 5.1 years) performed a multicomponent exercise program, which consisted of 4 weeks of walking, balance and cognitive exercises, followed by 4 weeks of resistance exercise performed twice weekly [8–12 repetitions at 20–50 % of the one-repetition maximum (1RM)], combined with walking, balance and cognitive exercises. Before and after training, as well as after 24 weeks of training cessation, strength outcomes, Barthel Index, balance, gait ability, rise from a chair ability, dual task performance, incidence of falls and Mini-Mental State Examination were assessed. After the first 4 weeks of training, there was a significant improvement only in the balance test, whereas no additional changes were observed. However, after the second part of the training, the participants required significantly less time for the time-up-and-go test (P < 0.05), and improved the isometric hand grip, hip flexion and knee extension strength, as well as the leg press 1RM (P < 0.01). A significant reduction was also observed in the incidence of falls (P < 0.01). After 24 weeks of training cessation, abrupt decreases were observed in nearly all of the physical outcomes (P < 0.05). The exercise intervention improved strength, balance and gait ability in frail elderly patients with dementia after long-term physical restraint, and these benefits were lost after training cessation.
PMCID: PMC4039260  PMID: 24243397
Frailty; Oldest old; Cognitive impairment; Dual-task walking; Multicomponent exercise
20.  Balance Confidence Improves with Resistance or Agility training: Increase is not Correlated with Objective Changes in Fall Risk and Physical Abilities 
Gerontology  2004;50(6):373-382.
While the fear of falling is a common psychological consequence of falling, older adults who have not fallen also frequently report this fear. Fear of falling can lead to activity restriction that is self-imposed rather than due to actual physical impairments. Evidence suggests that exercise can significantly improve balance confidence, as measured by falls-related self-efficacy scales. However, there are no prospective reports that correlate change in balance confidence with changes in fall risk and physical abilities as induced by participating in a group-based exercise program.
The primary purpose of this prospective study was to examine the relationship between the change in balance confidence and the changes in fall risk and physical abilities in older women with confirmed low bone mass after 13 weeks of exercise participation. The secondary purpose of this study was to examine the relationship between the change in balance confidence and the change in physical activity level.
The sample comprised 98 women aged 75 to 85 years old women with low bone mass. Participants were randomly assigned to one of three groups: Resistance Training (n=32), Agility Training (n=34), and Stretching (sham) exercises (n=32). The 50-minute exercise classes for each study arm were held twice weekly at a local YMCA community centre.
Both resistance training and agility training significantly improved balance confidence by 6% from baseline after 13 weeks. However, the change in balance confidence was only weakly correlated with improved general physical function and not significantly correlated with the changes in fall risk score, postural stability, gait speed, or physical activity level. As well, we observed balance confidence enhancement in the presence of increased fall risk or deterioration in physical abilities.
Two different types of exercise training improved balance confidence in older women with low bone mass. This change in balance confidence was significantly correlated with change in general physical function. Because of the observation of discordance between balance confidence change and changes in fall risk and physical abilities, those who design group-based exercise programs for community-dwelling older adults may wish to consider including an education component on factors that influence fear of falling. Objective changes in fall risk factors cannot be assumed to mirror change of fear of falling and physical abilities in older adults in the short-term.
PMCID: PMC3383061  PMID: 15477698 CAMSID: cams2199
Balance confidence; fall risk; exercise; older women; low bone mass
21.  Tai Chi and Postural Stability in Patients with Parkinson's Disease 
The New England Journal of Medicine  2012;366(6):511-519.
Patients with Parkinson's disease have substantially impaired balance, leading to diminished functional ability and an increased risk of falling. Although exercise is routinely encouraged by health care providers, few programs have been proven effective.
We conducted a randomized, controlled trial to determine whether a tailored tai chi program could improve postural control in patients with idiopathic Parkinson's disease. We randomly assigned 195 patients with stage 1 to 4 disease on the Hoehn and Yahr staging scale (which ranges from 1 to 5, with higher stages indicating more severe disease) to one of three groups: tai chi, resistance training, or stretching. The patients participated in 60-minute exercise sessions twice weekly for 24 weeks. The primary outcomes were changes from baseline in the limits-of-stability test (maximum excursion and directional control; range, 0 to 100%). Secondary outcomes included measures of gait and strength, scores on functional-reach and timed up-and-go tests, motor scores on the Unified Parkinson's Disease Rating Scale, and number of falls.
The tai chi group performed consistently better than the resistance-training and stretching groups in maximum excursion (between-group difference in the change from baseline, 5.55 percentage points; 95% confidence interval [CI], 1.12 to 9.97; and 11.98 percentage points; 95% CI, 7.21 to 16.74, respectively) and in directional control (10.45 percentage points; 95% CI, 3.89 to 17.00; and 11.38 percentage points; 95% CI, 5.50 to 17.27, respectively). The tai chi group also performed better than the stretching group in all secondary outcomes and outperformed the resistance-training group in stride length and functional reach. Tai chi lowered the incidence of falls as compared with stretching but not as compared with resistance training. The effects of tai chi training were maintained at 3 months after the intervention. No serious adverse events were observed.
Tai chi training appears to reduce balance impairments in patients with mild-to-moderate Parkinson's disease, with additional benefits of improved functional capacity and reduced falls. (Funded by the National Institute of Neurological Disorders and Stroke; number, NCT00611481.)
PMCID: PMC3285459  PMID: 22316445
22.  A best practice fall prevention exercise program to improve balance, strength / power, and psychosocial health in older adults: study protocol for a randomized controlled trial 
BMC Geriatrics  2013;13:105.
With increasing age neuromuscular deficits (e.g., sarcopenia) may result in impaired physical performance and an increased risk for falls. Prominent intrinsic fall-risk factors are age-related decreases in balance and strength / power performance as well as cognitive decline. Additional studies are needed to develop specifically tailored exercise programs for older adults that can easily be implemented into clinical practice. Thus, the objective of the present trial is to assess the effects of a fall prevention program that was developed by an interdisciplinary expert panel on measures of balance, strength / power, body composition, cognition, psychosocial well-being, and falls self-efficacy in healthy older adults. Additionally, the time-related effects of detraining are tested.
Healthy old people (n = 54) between the age of 65 to 80 years will participate in this trial. The testing protocol comprises tests for the assessment of static / dynamic steady-state balance (i.e., Sharpened Romberg Test, instrumented gait analysis), proactive balance (i.e., Functional Reach Test; Timed Up and Go Test), reactive balance (i.e., perturbation test during bipedal stance; Push and Release Test), strength (i.e., hand grip strength test; Chair Stand Test), and power (i.e., Stair Climb Power Test; countermovement jump). Further, body composition will be analysed using a bioelectrical impedance analysis system. In addition, questionnaires for the assessment of psychosocial (i.e., World Health Organisation Quality of Life Assessment-Bref), cognitive (i.e., Mini Mental State Examination), and fall risk determinants (i.e., Fall Efficacy Scale – International) will be included in the study protocol. Participants will be randomized into two intervention groups or the control / waiting group. After baseline measures, participants in the intervention groups will conduct a 12-week balance and strength / power exercise intervention 3 times per week, with each training session lasting 30 min. (actual training time). One intervention group will complete an extensive supervised training program, while the other intervention group will complete a short version ('3 times 3’) that is home-based and controlled by weekly phone calls. Post-tests will be conducted right after the intervention period. Additionally, detraining effects will be measured 12 weeks after program cessation. The control group / waiting group will not participate in any specific intervention during the experimental period, but will receive the extensive supervised program after the experimental period.
It is expected that particularly the supervised combination of balance and strength / power training will improve performance in variables of balance, strength / power, body composition, cognitive function, psychosocial well-being, and falls self-efficacy of older adults. In addition, information regarding fall risk assessment, dose–response-relations, detraining effects, and supervision of training will be provided. Further, training-induced health-relevant changes, such as improved performance in activities of daily living, cognitive function, and quality of life, as well as a reduced risk for falls may help to lower costs in the health care system. Finally, practitioners, therapists, and instructors will be provided with a scientifically evaluated feasible, safe, and easy-to-administer exercise program for fall prevention.
Trial registration Identifier: NCT01906034
PMCID: PMC3852637  PMID: 24106864
Seniors; Fall risk assessment; Resistance training; Postural stability
23.  Progressive resistance exercise increases strength but does not improve objective measures of mobility in young people with cerebral palsy 
Journal of physiotherapy  2014;60(1):58.
Does progressive resistance training (PRT) improve mobility and muscle strength in young people with cerebral palsy (CP)?
Randomised, controlled trial with concealed allocation and blinded outcome assessment.
Recruitment from a large metropolitan children's hospital and a CP register in Australia.
Participants had spastic diplegia CP, were aged 14 years to 22 years, had a disability classified as level II or III on the Gross Motor Function Classification System. Exclusion criteria were participation in PRT in the previous six months, single-event multi-level surgery in the previous two years, or contractures more than 20° at the hips and knees. Randomisation of 49 participants allocated 24 to the PRT group and 25 to the control group.
The intervention group participated in a twice-weekly, 12-week PRT program performed at community gymnasia. Training was completed alone or in pairs under the supervision of a physiotherapist. Each participant was prescribed four to six individualised exercises, which were targeted to address deficits that had been identified by instrumented gait analysis, supplemented by clinical assessment. Participants completed three sets of 10 to 12 repetitions of each exercise at an intensity of 60% to 80% of one repetition maximum (RM). The control group continued with their usual recreation and physiotherapy provided it did not include PRT.
Outcome measures
The primary outcome was the six-minute walk test at week 13 and at week 24. Secondary outcome measures assessed objective mobility-related function (self-selected walking speed, timed stairs test, Gross Motor Function Measure (GMFM-66) dimensions D and E, Gait Profile Score), participant-rated mobility (Functional Mobility Scale, Functional Assessment Questionnaire) and muscle performance (1-RM) of leg press and reverse leg press).
Forty-eight participants completed the study. After 12 weeks of training, there was no difference between the groups for the six-minute walk (0.1 m, 95% CI -20.6 to 20.9), stairs test (-0.9 s, 95% CI -4.7 to 2.9), GMFM dimension D (-1.3%, 95% CI -4.8 to 2.4) and E (0.9%, 95% CI -3.0 to 4.7), and reverse leg press 1-RM (-0.7 kg, 95% CI -4.3 to 2.8). The intervention group showed significant improvement in the Functional Mobility Scale at 5 m (0.6 units, 95% CI 0.1 to 1.1), the Functional Assessment Questionnaire (0.8 units, 95% CI 0.1 to 1.6) and leg press 1-RM (14.8 kg, 95% CI 4.3 to 25.3), compared with the control group. At week 24, there were no differences between the groups for any outcome. The groups did not significantly differ for the remaining secondary outcomes at either time-point.
Individualised PRT increases strength in young people with CP. The participants thought their mobility had improved, although objectively it had not.
PMCID: PMC4096970  PMID: 24856945
24.  Does multicomponent physical exercise with simultaneous cognitive training boost cognitive performance in older adults? A 6-month randomized controlled trial with a 1-year follow-up 
Clinical Interventions in Aging  2015;10:1335-1349.
Cognitive impairment is a health problem that concerns almost every second elderly person. Physical and cognitive training have differential positive effects on cognition, but have been rarely applied in combination. This study evaluates synergistic effects of multicomponent physical exercise complemented with novel simultaneous cognitive training on cognition in older adults. We hypothesized that simultaneous cognitive–physical components would add training specific cognitive benefits compared to exclusively physical training.
Seniors, older than 70 years, without cognitive impairment, were randomly assigned to either: 1) virtual reality video game dancing (DANCE), 2) treadmill walking with simultaneous verbal memory training (MEMORY), or 3) treadmill walking (PHYS). Each program was complemented with strength and balance exercises. Two 1-hour training sessions per week over 6 months were applied. Cognitive performance was assessed at baseline, after 3 and 6 months, and at 1-year follow-up. Multiple regression analyses with planned comparisons were calculated.
Eighty-nine participants were randomized to the three groups initially, 71 completed the training, while 47 were available at 1-year follow-up. Advantages of the simultaneous cognitive–physical programs were found in two dimensions of executive function. “Shifting attention” showed a time×intervention interaction in favor of DANCE/MEMORY versus PHYS (F[2, 68] =1.95, trend P=0.075, r=0.17); and “working memory” showed a time×intervention interaction in favor of DANCE versus MEMORY (F[1, 136] =2.71, trend P=0.051, R2=0.006). Performance improvements in executive functions, long-term visual memory (episodic memory), and processing speed were maintained at follow-up in all groups.
Particular executive functions benefit from simultaneous cognitive–physical training compared to exclusively physical multicomponent training. Cognitive–physical training programs may counteract widespread cognitive impairments in the elderly.
PMCID: PMC4544626  PMID: 26316729
elderly; executive function; transfer; cognitive impairment; dance; video game
25.  Beneficial effects of short-term combination exercise training on diverse cognitive functions in healthy older people: study protocol for a randomized controlled trial 
Trials  2012;13:200.
Results of previous studies have shown that exercise training can improve cognitive functions in healthy older people. Some studies have demonstrated that long-term combination exercise training can facilitate memory function improvement better than either aerobic or strength exercise training alone. Nevertheless, it remains unclear whether short-term combination exercise training can improve diverse cognitive functions in healthy older people or not. We investigate the effects of four weeks of short-term combination exercise training on various cognitive functions (executive functions, episodic memory, short-term memory, working memory, attention, reading ability, and processing speed) of healthy older people.
A single-blinded intervention with two parallel groups (combination exercise training; waiting list control) is used. Testers are blind to the study hypothesis and the participants’ group membership. Through an advertisement in a local newspaper, 64 healthy older adults are recruited and then assigned randomly to a combination exercise training group or a waiting list control group. Participants in the combination exercise training group must participate in the short-term combination exercise training (aerobic and strength exercise training) three days per week during the four weeks (12 workouts in total). The waiting list group does not participate in the combination exercise training. The primary outcome measure is the Stroop test score: a measure of executive function. Secondary outcome measures are assessments including the Verbal Fluency Task, Logical Memory, First and Second Names, Digit Span Forward, Digit span backward, Japanese Reading Test, Digit Cancellation Task, Digit Symbol Coding, and Symbol Search. We assess these outcome measures before and after the intervention.
This report is the first of a study that investigates the beneficial effects of short-term combination exercise training on diverse cognitive functions of older people. Our study is expected to provide sufficient evidence of short-term combination exercise’s effectiveness.
Trial registration
This trial was registered in The University Hospital Medical Information Network Clinical Trials Registry (Number UMIN000007828).
PMCID: PMC3495024  PMID: 23107038

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