Cognitive-Motor Incorporated Training and Its Relations in Cerebrovascular Diseases With Cognitive and Motor Impairments

Global cognitive function will be assessed using the Taiwan 7.1 version of the Montreal Cognitive Assessment (MoCA). The test includes 16 items and 11 categories, evaluating multiple cognitive domains. It has been validated in various clinical populations and countries. Scores range from 0 to 30, higher scores indicate better performance.

The Trail Making Test-A (TMT-A) requires participants to sequentially connect 25 numbered dots, while the Chinese version of TMT-B involves alternating between numbers (1-12) and Chinese zodiac signs (rat to pig). The Chinese TMT-B is a reliable tool for assessing executive function in older adults. Completion time (lower is better) is the primary outcome, with error rates also recorded.

The Chinese version of Stroop Color and Word Test (SCWT) consists of two parts: (1) a congruent condition, where participants read color-words printed in matching ink, and (2) an incongruent condition, where they identify the ink color of mismatched color-words (e.g., "black" printed in blue). Participants execute 45 seconds per task, and scores are based on the number of correct responses. Higher scores indicate better performance. The Chinese SCWT is a reliable EF assessment for older adults.

Digit Span Test (DS) consists of 8 items with 2 trials each, starting with 2-digit sequences and increasing to 9 digits. Participants repeat the digits in the order presented, scoring 1 point per correct response. Testing ends when both trials for an item are incorrect. Scores range from 0 to 16, with higher scores indicating better performance.

Cognitive flexibility was evaluated using a Naming test. Participants name items within specific categories (fruits, vegetables, modes of transportation). They are given 1 minute to list as many items as possible from a single category, and the total number of correct responses is recorded.

Sensorimotor function after stroke will be measured by Fugl-Meyer Assessment for upper extremity (FMA-UE) and lower extremity (FMA-LE). The FMA-UE includes subtests evaluating the upper extremity, wrist, hand, and coordination/speed, with scores ranging from 0 to 66. The FMA-LE comprises 17 items that measure reflexes, movement, and coordination of the lower extremity, scored on a 3-point ordinal scale (0-2), with a total score of 34 points. Higher scores indicate better motor recovery. The validity and reliability of both assessments are well established.

Bilateral muscle strength of the shoulder flexors, elbow flexors, wrist extensors, ankle flexors/extensors, knee flexors/extensors, hip flexors/extensors, and hip abductors will be measured using a wireless handheld dynamometer (microFET2, Hoggan Industries, Inc., West Jordan, UT, USA). Each muscle group will be tested twice, with participants performing maximal contractions for 6 seconds per trial. A 30-second rest period will be provided between trials to prevent fatigue. The average of the two maximal efforts will be recorded.

Ambulation ability will be evaluated using the Functional Ambulatory Category (FAC), a 6-level scale (0-5). Level 0 indicates the inability to walk, while level 5 represents complete independence. Intermediate levels reflect varying degrees of required assistance or supervision.

Dual-task cost (DTC) will be calculated to perform the difference between single-task and dual-task condition, expressed as a percentage. The DTC will be calculated as: (Dual task measure - Single task measure) / Single task measure x 100%.

For the single task, participants will stand still with a feet-together standing posture for 30 seconds, while for the dual task, they will continuously subtract 1 from a random 2-digit number while maintaining standing posture. Each condition will include a 1-minute rest period and will be repeated for three trials to ensure consistency.

During the single and dual tasking, kinematic performance will be assessed using the 95% ellipse sway area and RMS sway, recorded by 3 wearable inertial sensors (APDM Mobility Lab® Opal system) placed bilaterally at the ankles and at the 5th lumbar vertebra. Postural sway analysis will include angle (degrees), mean velocity, acceleration, and jerk of the sway trajectory.

Oxyhemoglobin [HbO] will be measured using a multichannel wearable Functional Near-Infrared Spectroscopy (fNIRS) imaging system (NIRSport2, NIRx Medical Technologies LLC, Glen Head, NYC, USA), which emits and receives dual-wavelength near-infrared signals at 760 and 850 nm.

Deoxyhemoglobin [HbR] will be measured using a multichannel wearable Functional Near-Infrared Spectroscopy (fNIRS) imaging system (NIRSport2, NIRx Medical Technologies LLC, Glen Head, NYC, USA), which emits and receives dual-wavelength near-infrared signals at 760 and 850 nm.

Hemoglobin difference levels (Hbdiff) will be measured using a multichannel wearable Functional Near-Infrared Spectroscopy (fNIRS) imaging system (NIRSport2, NIRx Medical Technologies LLC, Glen Head, NYC, USA), which emits and receives dual-wavelength near-infrared signals at 760 and 850 nm.

The Modified Rankin Scale (mRS) assesses disability levels in ADL, ranging from 0 (no symptoms) to 6 (death). Scores between 1 and 5 reflect increasing levels of disability, from slight (independent) to severe (bedridden), with higher scores indicating lower functional ability.

The Functional Independence Measure (FIM) will be used to evaluate subjects' ADL abilities. The FIM includes 18 motor and cognitive items, with total scores ranging from 18 to 126. Higher scores indicate greater independence.

The Instrumental Activity of Daily Living (IADL) scale evaluates independence across eight domains: telephone use, shopping, food preparation, housekeeping, laundry, transportation, medication management, and financial handling. Scores range from 0 (lowest independence) to 8 (highest independence), with higher scores indicating greater functional ability.

Depression will be assessed using the Hospital Anxiety and Depression Scale (HADS), specifically the depression subscale. Scores of 8-10 indicate mild depression, 11-14 moderate, and 15-21 severe, with higher scores reflecting greater depressive symptoms.

Quality of Life will be measured using the 36-item Short Form Health Survey (SF-36). The validated Taiwanese version will be used, which has strong psychometric properties. Higher scores indicate better health-related quality of life.

To track whether participants are able to return to work or re-enter their occupational environment, a telephone interview will be conducted at the 1-year follow-up. If a participant is able to return to work but requires adjustments to their job role or a change in occupation, this information will be documented in detailed notes.