Effects of Strategy Training for Physical Activity (STPA) on the Post-stroke Executive Dysfunction

Effects of Strategy Training for Physical Activity on Executive Functions in Stroke Survivors With Cognitive Impairments: a Phase II Randomized Controlled Trial

The goal of this randomized controlled trial is to examine if combining strategy training and physical activity (STPA) works to improve executive function in community-dwelling adults with post-stroke cognitive impairment. The main questions it aims to answer are:

• Does STPA and physical exercise alone lead to greater improvements in executive function among stroke survivors relative to the control intervention with education?
• Does STPA outperform physical exercise alone in the efficacy of executive functions?
• Do the effects of STPA on executive functions transfer to the global cognition, balance, and activity-participation outcomes?
• Do the effects of STPA persist for at least 6 months post-intervention?

Researchers will compare the efficacy of the STPA intervention against physical exercise alone or control intervention with education.

Participants will:

receive STPA, physical activity only, or an education program 2 to 3 sessions per week until finishing 12 sessions.

be assessed clinical outcomes at 5 times: pre-intervention, post-intervention, 3-month, 6-month, and 12-month follow-up.

Poststroke cognitive impairment is a prevalent consequence of stroke that significantly impacts multifaceted outcomes. Executive functions are particularly responsive to training among cognitive domains. Despite the accumulating literature supporting physical activity interventions, their effects have been observed to be small and time-limited. Incorporating a behavioral approach, such as strategy training, offers a promising avenue for promoting improvements in executive functions and related stroke outcomes. To the best of investigators' understanding, no study has examined whether combining strategy training with physical activity-oriented goals can ameliorate executive and cognitive functions in individuals with stroke.

This study aims to examine and compare the efficacy of STPA and physical activity alone on executive, cognitive, activity, and participation functions in people with poststroke cognitive impairments. This study addresses the following specific aims:

1. Determine whether STPA in stroke patients with PSCI produces immediate improvements in executive functions that may generalize to improved global cognition, activity, or participation outcomes to a greater extent than a control intervention focused on stroke-related education;
2. Examine the potential association between improvements in executive functions resulting from STPA and enhancements in activity and participation performance;
3. Investigate the duration of therapeutic effects of STPA following the intervention;

To achieve these aims, a three-armed, parallel-design, randomized phase II clinical trial is designed and conducted. The investigators plan to recruit an expected sample of 120 adults with poststroke cognitive impairments from collaborative sites in northern Taiwan. Eligible participants are randomly assigned to one of the three intervention groups (STPA, physical activity, and education) at a 1:1:1 ratio. All participants should receive 12 sessions lasting 60 minutes over a maximum of 6 weeks. Primary outcomes for executive functions (Trail Making Test Part B and color-word condition of Stroop Color and Word Test) and secondary outcome measures, including Montreal Cognitive Assessment, processing speed (Trail Making Test Part A and word condition of Stroop Color and Word Test), Self-Regulation Skills Interview, Activity Measure for Post-Acute Care Outpatient Short Forms, Participation Measure-3 Domains, 4 Dimensions, Timed-Up and Go test, and Taiwan version of the International Physical Activity Questionnaire are administered at baseline (T1), post-intervention (T2), and 3-month (T3), 6-month (T4), and 12-month (T5) follow-ups. Data will be analyzed using constrained longitudinal data analysis and mixed-effects regression models. Additionally, qualitative in-depth interviews will be conducted with participants, caregivers, and therapists to understand their experiences, satisfaction, and their perceived effectiveness of the intervention. Transcribed data will be coded and analyzed with thematic analysis method.

Inclusion Criteria:

• 18 to 80 years old
• A diagnosis of stroke within the past 3 year
• Speaking Mandarin
• Montreal Cognitive Assessment (maximum=30) < 26
• 14 item-Executive Interview > 3
• Willing to provide informed consent

Exclusion Criteria:

• Modified Rankin Scale (mRS) = 5
• Any conditions that may impede the participation in the study, such as severe aphasia, postoperative immobilization, or major neuropsychiatric diseases.
• Pre-stroke mRS >1
• 6-level Saltin-Grimby Physical Activity Level Scale (SGPALS) = 5 or 6
• Participating in other interventional study concurrently