Effects of Transcutaneous Electrical Nerve Stimulation on Cognitive Function and Upper Limb Motor Function in People With Chronic Stroke

Chronic Stroke Clinical Trial

Official title:

A Randomized Controlled Clinical Trial of Transcutaneous Electrical Nerve Stimulation on Cognitive Function and Upper Limb Motor Function in People With Chronic Stroke

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05615610
• Other study ID #: 2022_TVNS_STROKE
• Status: Recruiting
• Phase: N/A
• Start date: December 1, 2022
• Est. completion date: December 1, 2024

Study information

• Verified date: February 2024
• Source: The Hong Kong Polytechnic University
• Contact: Shamay NG, PhD
• Phone: +852 27664889
• Email: shamay.ng[@]polyu.edu.hk
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Upper limb impairment is present in more than 85% of people with stroke, which greatly affect the quality of life, social participation, and performance of daily activities of people with stroke. Previous study also revealed that 53.4% of people after stroke experienced cognitive impairment. Different cognitive domains might be affected following stroke, such as attention, memory, language, and orientation, and the problems with memory are often prominent. Yet, there is no effective treatment for the post-stroke cognitive impairment. Transcutaneous electrical nerve stimulation (TENS) applied on thoracic region and transcutaneous vagus nerve stimulation (tVNS) are simple and non-invasive treatment to improve upper limb motor function and cognitive function. However, no existing studies have explored on the effects of TENS and tVNS on cognitive function in people with stroke. Therefore, the purpose of this study is to evaluate the effectiveness of TENS on improving upper limb function and cognitive function in people with chronic stroke. Also, this study will investigate the cortical response of people with stroke during TENS by using EEG power spectrum analysis.

Description:

This study aims to investigate the effects of three intervention protocols in people with stroke. The participants in Group A will receive TENS on C6 and T5 level of the spine with upper limb exercises. The participants in Group B will receive tVNS on the cymba conchae of left outer ear with upper limb exercises. The participants in Group C will receive placebo tVNS with upper limb exercises.

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 75
• Est. completion date: December 1, 2024
• Est. primary completion date: December 1, 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 50 Years to 80 Years

Eligibility

Inclusion Criteria:

1. aged between 50 and 80;

2. have suffered from a single stroke at least 1 year;

3. had volitional control of the non-paretic arm and at least minimal antigravity movement in the paretic shoulder;

4. scored 7 or above in the Abbreviated Mental Test.

Exclusion Criteria:

1. have cardiac pacemaker or cochlear implant;

2. have other neurological diseases;

3. are taking medication that may affect measured outcomes;

4. have skin lesions, infection, or inflammation near selected position;

5. are participating in other drug/treatment programs.

Related Conditions & MeSH terms

• Chronic Stroke
• Stroke

Intervention

Device:
• spine TENS
The participants in Group A will receive TENS (Burst mode, 9 pulses per burst, pulse frequency = 160 Hz, burst frequency = 2 Hz) with upper limb exercises. The electrical stimulation will be generated by the neurostimulator (MH8000P; MEDIHIGHTEC MEDICAL CO., LTD., Taiwan). Two 7.5 × 12.6 cm electrodes will be attached between C6 and T5 level on each side of spinal column and with 2 cm from the spine. Intensity of TENS will be individually selected by the participants according to tolerance levels.
• tVNS
The participants in Group B will receive tVNS (pulse frequency = 25Hz, pulse duration = 0.3 ms) on the cymba conchae of left outer ear with upper limb exercises.The electrical stimulation will be generated by the neurostimulator (MH8000P; MEDIHIGHTEC MEDICAL CO., LTD., Taiwan). Intensity of tVNS will be individually selected by the participants according to tolerance levels. Previous studies showed that it was effective to improve the upper limb motor function in people with stroke and cognitive function in people with mild cognitive function.
• Control
The participants in Group C will receive placebo tVNS with upper limb exercises, where the stimulation will be delivered by placebo-TENS device with disconnected electrical circuit.

Locations

Country	Name	City	State
Hong Kong	The Hong Kong Polytechnic University	Hong Kong

Sponsors (1)

Lead Sponsor	Collaborator
The Hong Kong Polytechnic University

Country where clinical trial is conducted

Hong Kong, 

References & Publications (33)

Agius Anastasi A, Falzon O, Camilleri K, Vella M, Muscat R. Brain Symmetry Index in Healthy and Stroke Patients for Assessment and Prognosis. Stroke Res Treat. 2017;2017:8276136. doi: 10.1155/2017/8276136. Epub 2017 Jan 30. — View Citation

Al-Qazzaz NK, Ali SH, Ahmad SA, Islam S, Mohamad K. Cognitive impairment and memory dysfunction after a stroke diagnosis: a post-stroke memory assessment. Neuropsychiatr Dis Treat. 2014 Sep 9;10:1677-91. doi: 10.2147/NDT.S67184. eCollection 2014. — View Citation

Ashford S, Slade M, Turner-Stokes L. Conceptualisation and development of the arm activity measure (ArmA) for assessment of activity in the hemiparetic arm. Disabil Rehabil. 2013 Aug;35(18):1513-8. doi: 10.3109/09638288.2012.743602. Epub 2013 Jan 7. — View Citation

Barbay M, Diouf M, Roussel M, Godefroy O; GRECOGVASC study group. Systematic Review and Meta-Analysis of Prevalence in Post-Stroke Neurocognitive Disorders in Hospital-Based Studies. Dement Geriatr Cogn Disord. 2018;46(5-6):322-334. doi: 10.1159/000492920. Epub 2018 Nov 30. — View Citation

Britton JW, Frey LC, Hopp JL, Korb P, Koubeissi MZ, Lievens WE, Pestana-Knight EM, St. Louis EK, authors. St. Louis EK, Frey LC, editors. Electroencephalography (EEG): An Introductory Text and Atlas of Normal and Abnormal Findings in Adults, Children, and Infants [Internet]. Chicago: American Epilepsy Society; 2016. Available from http://www.ncbi.nlm.nih.gov/books/NBK390354/ — View Citation

de Paula JJ, Malloy-Diniz LF, Romano-Silva MA. Reliability of working memory assessment in neurocognitive disorders: a study of the Digit Span and Corsi Block-Tapping tasks. Braz J Psychiatry. 2016 Jul-Sep;38(3):262-3. doi: 10.1590/1516-4446-2015-1879. No abstract available. — View Citation

Desrosiers J, Noreau L, Rochette A, Bourbonnais D, Bravo G, Bourget A. Predictors of long-term participation after stroke. Disabil Rehabil. 2006 Feb 28;28(4):221-30. doi: 10.1080/09638280500158372. — View Citation

Fong KNK, Lee KKL, Tsang ZPY, Wan JYH, Zhang YY, Lau AFC. The clinical utility, reliability and validity of the Rivermead Behavioural Memory Test-Third Edition (RBMT-3) in Hong Kong older adults with or without cognitive impairments. Neuropsychol Rehabil. 2019 Jan;29(1):144-159. doi: 10.1080/09602011.2016.1272467. Epub 2017 Jan 4. — View Citation

Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31. — View Citation

Ingwersen T, Wolf S, Birke G, Schlemm E, Bartling C, Bender G, Meyer A, Nolte A, Ottes K, Pade O, Peller M, Steinmetz J, Gerloff C, Thomalla G. Long-term recovery of upper limb motor function and self-reported health: results from a multicenter observational study 1 year after discharge from rehabilitation. Neurol Res Pract. 2021 Dec 27;3(1):66. doi: 10.1186/s42466-021-00164-7. — View Citation

Jenkinson C, Kelly L, Dummett S, Morley D. The Oxford Participation and Activities Questionnaire (Ox-PAQ): development of a short form and index measure. Patient Relat Outcome Meas. 2019 Jul 29;10:227-232. doi: 10.2147/PROM.S210416. eCollection 2019. — View Citation

Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, Jones L, Krassioukov A, Mulcahey MJ, Schmidt-Read M, Waring W. International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011 Nov;34(6):535-46. doi: 10.1179/204577211X13207446293695. No abstract available. — View Citation

Lam ET, Lam CL, Fong DY, Huang WW. Is the SF-12 version 2 Health Survey a valid and equivalent substitute for the SF-36 version 2 Health Survey for the Chinese? J Eval Clin Pract. 2013 Feb;19(1):200-8. doi: 10.1111/j.1365-2753.2011.01800.x. Epub 2011 Nov 29. — View Citation

Lam SC, Wong YY, Woo J. Reliability and validity of the abbreviated mental test (Hong Kong version) in residential care homes. J Am Geriatr Soc. 2010 Nov;58(11):2255-7. doi: 10.1111/j.1532-5415.2010.03129.x. No abstract available. — View Citation

Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011 May 14;377(9778):1693-702. doi: 10.1016/S0140-6736(11)60325-5. — View Citation

Leung JL, Lee GT, Lam YH, Chan RC, Wu JY. The use of the Digit Span Test in screening for cognitive impairment in acute medical inpatients. Int Psychogeriatr. 2011 Dec;23(10):1569-74. doi: 10.1017/S1041610211000792. Epub 2011 May 17. — View Citation

Michaelsen SM, Rocha AS, Knabben RJ, Rodrigues LP, Fernandes CG. Translation, adaptation and inter-rater reliability of the administration manual for the Fugl-Meyer assessment. Rev Bras Fisioter. 2011 Jan-Feb;15(1):80-8. — View Citation

Morley D, Dummett S, Kelly L, Dawson J, Fitzpatrick R, Jenkinson C. Validation of the Oxford Participation and Activities Questionnaire. Patient Relat Outcome Meas. 2016 Jun 15;7:73-80. doi: 10.2147/PROM.S96822. eCollection 2016. — View Citation

Nakayama H, Jorgensen HS, Raaschou HO, Olsen TS. Recovery of upper extremity function in stroke patients: the Copenhagen Stroke Study. Arch Phys Med Rehabil. 1994 Apr;75(4):394-8. doi: 10.1016/0003-9993(94)90161-9. — View Citation

Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum In: J Am Geriatr Soc. 2019 Sep;67(9):1991. — View Citation

Nichols-Larsen DS, Clark PC, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors' quality of life during subacute recovery. Stroke. 2005 Jul;36(7):1480-4. doi: 10.1161/01.STR.0000170706.13595.4f. Epub 2005 Jun 9. — View Citation

REITAN RM. The relation of the trail making test to organic brain damage. J Consult Psychol. 1955 Oct;19(5):393-4. doi: 10.1037/h0044509. No abstract available. — View Citation

Scherder EJ, Bouma A, Steen LM. Effects of "isolated" transcutaneous electrical nerve stimulation on memory and affective behavior in patients with probable Alzheimer's disease. Biol Psychiatry. 1998 Mar 15;43(6):417-24. doi: 10.1016/s0006-3223(97)00208-4. — View Citation

Scherder EJ, Bouma A. Effects of transcutaneous electrical nerve stimulation on memory and behavior in Alzheimer's disease may be stage-dependent. Biol Psychiatry. 1999 Mar 15;45(6):743-9. doi: 10.1016/s0006-3223(98)00072-9. — View Citation

Schleiger E, Sheikh N, Rowland T, Wong A, Read S, Finnigan S. Frontal EEG delta/alpha ratio and screening for post-stroke cognitive deficits: the power of four electrodes. Int J Psychophysiol. 2014 Oct;94(1):19-24. doi: 10.1016/j.ijpsycho.2014.06.012. Epub 2014 Jun 24. — View Citation

Sheorajpanday RV, Nagels G, Weeren AJ, van Putten MJ, De Deyn PP. Reproducibility and clinical relevance of quantitative EEG parameters in cerebral ischemia: a basic approach. Clin Neurophysiol. 2009 May;120(5):845-55. doi: 10.1016/j.clinph.2009.02.171. Epub 2009 Apr 16. — View Citation

Sun JH, Tan L, Yu JT. Post-stroke cognitive impairment: epidemiology, mechanisms and management. Ann Transl Med. 2014 Aug;2(8):80. doi: 10.3978/j.issn.2305-5839.2014.08.05. — View Citation

van Putten MJ. The revised brain symmetry index. Clin Neurophysiol. 2007 Nov;118(11):2362-7. doi: 10.1016/j.clinph.2007.07.019. Epub 2007 Sep 20. — View Citation

Wang L, Zhang J, Guo C, He J, Zhang S, Wang Y, Zhao Y, Li L, Wang J, Hou L, Li S, Wang Y, Hao L, Zhao Y, Wu M, Fang J, Rong P. The efficacy and safety of transcutaneous auricular vagus nerve stimulation in patients with mild cognitive impairment: A double blinded randomized clinical trial. Brain Stimul. 2022 Nov-Dec;15(6):1405-1414. doi: 10.1016/j.brs.2022.09.003. Epub 2022 Sep 21. — View Citation

Whitall J, Savin DN Jr, Harris-Love M, Waller SM. Psychometric properties of a modified Wolf Motor Function test for people with mild and moderate upper-extremity hemiparesis. Arch Phys Med Rehabil. 2006 May;87(5):656-60. doi: 10.1016/j.apmr.2006.02.004. — View Citation

Wolf SL, Thompson PA, Morris DM, Rose DK, Winstein CJ, Taub E, Giuliani C, Pearson SL. The EXCITE trial: attributes of the Wolf Motor Function Test in patients with subacute stroke. Neurorehabil Neural Repair. 2005 Sep;19(3):194-205. doi: 10.1177/1545968305276663. — View Citation

Wu D, Ma J, Zhang L, Wang S, Tan B, Jia G. Effect and Safety of Transcutaneous Auricular Vagus Nerve Stimulation on Recovery of Upper Limb Motor Function in Subacute Ischemic Stroke Patients: A Randomized Pilot Study. Neural Plast. 2020 Aug 1;2020:8841752. doi: 10.1155/2020/8841752. eCollection 2020. — View Citation

Yeung PY, Wong LL, Chan CC, Leung JL, Yung CY. A validation study of the Hong Kong version of Montreal Cognitive Assessment (HK-MoCA) in Chinese older adults in Hong Kong. Hong Kong Med J. 2014 Dec;20(6):504-10. doi: 10.12809/hkmj144219. Epub 2014 Aug 15. — View Citation

* Note: There are 33 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Fugl-Meyer Assessment of the Upper Extremity	The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) assesses the motor control, which included the reflex, synergistic and isolated movements and coordination of the upper extremity. It is a 3-point ordinal scale with 33 items and the total score ranges from 0 to 66. In this scale, "0" represents "cannot perform", "1" represents "performs partially" and "2" represents "performs fully". The higher score indicates better motor control of the upper extremity. The FMA-UE has an excellent inter-rater reliability (ICC = 0.98) in people with stroke.	Baseline (0 week)
Primary	Fugl-Meyer Assessment of the Upper Extremity	The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) assesses the motor control, which included the reflex, synergistic and isolated movements and coordination of the upper extremity. It is a 3-point ordinal scale with 33 items and the total score ranges from 0 to 66. In this scale, "0" represents "cannot perform", "1" represents "performs partially" and "2" represents "performs fully". The higher score indicates better motor control of the upper extremity. The FMA-UE has an excellent inter-rater reliability (ICC = 0.98) in people with stroke.	Mid-intervention (3 week)
Primary	Fugl-Meyer Assessment of the Upper Extremity	The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) assesses the motor control, which included the reflex, synergistic and isolated movements and coordination of the upper extremity. It is a 3-point ordinal scale with 33 items and the total score ranges from 0 to 66. In this scale, "0" represents "cannot perform", "1" represents "performs partially" and "2" represents "performs fully". The higher score indicates better motor control of the upper extremity. The FMA-UE has an excellent inter-rater reliability (ICC = 0.98) in people with stroke.	Post-intervention (6 week)
Primary	Fugl-Meyer Assessment of the Upper Extremity	The Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) assesses the motor control, which included the reflex, synergistic and isolated movements and coordination of the upper extremity. It is a 3-point ordinal scale with 33 items and the total score ranges from 0 to 66. In this scale, "0" represents "cannot perform", "1" represents "performs partially" and "2" represents "performs fully". The higher score indicates better motor control of the upper extremity. The FMA-UE has an excellent inter-rater reliability (ICC = 0.98) in people with stroke.	1-month follow-up (10 week)
Primary	Wolf Motor Function Test	The Wolf Motor Function Test (WMFT) evaluates the motor ability of upper extremity through timed and functional tasks. It consists of 17 tasks which is rated by 6-point scale which ranges from 0 (no attempt made to use the more affected upper extremity) to 5 (movement appears to be normal). The time for completing each functional task is also recorded, with a maximum of 120 seconds allow for each task. The higher score represents the better functioning level of upper extremity, Excellent test-retest reliability (ICC = 0.92 - 0.99) has been demonstrated in people with stroke.	Baseline (0 week)
Primary	Wolf Motor Function Test	The Wolf Motor Function Test (WMFT) evaluates the motor ability of upper extremity through timed and functional tasks. It consists of 17 tasks which is rated by 6-point scale which ranges from 0 (no attempt made to use the more affected upper extremity) to 5 (movement appears to be normal). The time for completing each functional task is also recorded, with a maximum of 120 seconds allow for each task. The higher score represents the better functioning level of upper extremity, Excellent test-retest reliability (ICC = 0.92 - 0.99) has been demonstrated in people with stroke.	Mid-intervention (3 week)
Primary	Wolf Motor Function Test	The Wolf Motor Function Test (WMFT) evaluates the motor ability of upper extremity through timed and functional tasks. It consists of 17 tasks which is rated by 6-point scale which ranges from 0 (no attempt made to use the more affected upper extremity) to 5 (movement appears to be normal). The time for completing each functional task is also recorded, with a maximum of 120 seconds allow for each task. The higher score represents the better functioning level of upper extremity, Excellent test-retest reliability (ICC = 0.92 - 0.99) has been demonstrated in people with stroke.	Post-intervention (6 week)
Primary	Wolf Motor Function Test	The Wolf Motor Function Test (WMFT) evaluates the motor ability of upper extremity through timed and functional tasks. It consists of 17 tasks which is rated by 6-point scale which ranges from 0 (no attempt made to use the more affected upper extremity) to 5 (movement appears to be normal). The time for completing each functional task is also recorded, with a maximum of 120 seconds allow for each task. The higher score represents the better functioning level of upper extremity, Excellent test-retest reliability (ICC = 0.92 - 0.99) has been demonstrated in people with stroke.	1-month follow-up (10 week)
Primary	Muscle strength	A hand-held dynamometer (Model 01165; Lafayette Instrument, Indiana, USA) will be used to measure the muscle force generated by biceps brachii and triceps brachii muscles of affected and unaffected sides. The participant will be instructed to perform isometric contraction and resistance will be applied by the examiner to avoid movement of the arm during the measurement. Two trials will be performed for each muscle group and the mean force of two trials will be recorded.	Baseline (0 week)
Primary	Muscle strength	A hand-held dynamometer (Model 01165; Lafayette Instrument, Indiana, USA) will be used to measure the muscle force generated by biceps brachii and triceps brachii muscles of affected and unaffected sides. The participant will be instructed to perform isometric contraction and resistance will be applied by the examiner to avoid movement of the arm during the measurement. Two trials will be performed for each muscle group and the mean force of two trials will be recorded.	Mid-intervention (3 week)
Primary	Muscle strength	A hand-held dynamometer (Model 01165; Lafayette Instrument, Indiana, USA) will be used to measure the muscle force generated by biceps brachii and triceps brachii muscles of affected and unaffected sides. The participant will be instructed to perform isometric contraction and resistance will be applied by the examiner to avoid movement of the arm during the measurement. Two trials will be performed for each muscle group and the mean force of two trials will be recorded.	Post-intervention (6 week)
Primary	Muscle strength	A hand-held dynamometer (Model 01165; Lafayette Instrument, Indiana, USA) will be used to measure the muscle force generated by biceps brachii and triceps brachii muscles of affected and unaffected sides. The participant will be instructed to perform isometric contraction and resistance will be applied by the examiner to avoid movement of the arm during the measurement. Two trials will be performed for each muscle group and the mean force of two trials will be recorded.	1-month follow-up (10 week)
Primary	Muscle stiffness	The muscle stiffness of biceps brachii and triceps brachii muscles will be quantified by MyotonPRO device (Myoton AS, Tallinn, Estonia). The MyotonPRO device will be placed perpendicularly to the skin surface and apply mechanical impulses on the muscles to generate damped oscillations of the underlying tissue. The biceps brachii measurements will be performed at the long head of the muscle in the middle of the arm. The triceps brachii measurements will be performed at the medial head of the muscle in the middle of the arm. Muscle stiffness will be described as newton-meter (N/m), where the higher value indicates the higher stiffness of the tissue.	Baseline (0 week)
Primary	Muscle stiffness	The muscle stiffness of biceps brachii and triceps brachii muscles will be quantified by MyotonPRO device (Myoton AS, Tallinn, Estonia). The MyotonPRO device will be placed perpendicularly to the skin surface and apply mechanical impulses on the muscles to generate damped oscillations of the underlying tissue. The biceps brachii measurements will be performed at the long head of the muscle in the middle of the arm. The triceps brachii measurements will be performed at the medial head of the muscle in the middle of the arm. Muscle stiffness will be described as newton-meter (N/m), where the higher value indicates the higher stiffness of the tissue.	Mid-intervention (3 week)
Primary	Muscle stiffness	The muscle stiffness of biceps brachii and triceps brachii muscles will be quantified by MyotonPRO device (Myoton AS, Tallinn, Estonia). The MyotonPRO device will be placed perpendicularly to the skin surface and apply mechanical impulses on the muscles to generate damped oscillations of the underlying tissue. The biceps brachii measurements will be performed at the long head of the muscle in the middle of the arm. The triceps brachii measurements will be performed at the medial head of the muscle in the middle of the arm. Muscle stiffness will be described as newton-meter (N/m), where the higher value indicates the higher stiffness of the tissue.	Post-intervention (6 week)
Primary	Muscle stiffness	The muscle stiffness of biceps brachii and triceps brachii muscles will be quantified by MyotonPRO device (Myoton AS, Tallinn, Estonia). The MyotonPRO device will be placed perpendicularly to the skin surface and apply mechanical impulses on the muscles to generate damped oscillations of the underlying tissue. The biceps brachii measurements will be performed at the long head of the muscle in the middle of the arm. The triceps brachii measurements will be performed at the medial head of the muscle in the middle of the arm. Muscle stiffness will be described as newton-meter (N/m), where the higher value indicates the higher stiffness of the tissue.	1-month follow-up (10 week)
Primary	Rivermead Behavioural Memory Test - Third edition	The Rivermead Behavioural Memory Test - Third edition (RBMT-3) examines the everyday memory function with 14 subtests, including the assessment for visual, verbal, recall, recognition, immediate, and delayed memory. The scaled score of each subtest and total scaled score will be computed by converting raw scores based on different age group. Higher scaled score indicates better memory function. The RBMT-3 has demonstrated excellent inter-rater reliability (ICC = 0.997) and intra-rater reliability (ICC = 0.924) and good internal consistency (Cronbach's alpha = 0.643 - 0.832) in people with dementia, mild cognitive impairment and healthy older adults.	Baseline (0 week)
Primary	Rivermead Behavioural Memory Test - Third edition	The Rivermead Behavioural Memory Test - Third edition (RBMT-3) examines the everyday memory function with 14 subtests, including the assessment for visual, verbal, recall, recognition, immediate, and delayed memory. The scaled score of each subtest and total scaled score will be computed by converting raw scores based on different age group. Higher scaled score indicates better memory function. The RBMT-3 has demonstrated excellent inter-rater reliability (ICC = 0.997) and intra-rater reliability (ICC = 0.924) and good internal consistency (Cronbach's alpha = 0.643 - 0.832) in people with dementia, mild cognitive impairment and healthy older adults.	Mid-intervention (3 week)
Primary	Rivermead Behavioural Memory Test - Third edition	The Rivermead Behavioural Memory Test - Third edition (RBMT-3) examines the everyday memory function with 14 subtests, including the assessment for visual, verbal, recall, recognition, immediate, and delayed memory. The scaled score of each subtest and total scaled score will be computed by converting raw scores based on different age group. Higher scaled score indicates better memory function. The RBMT-3 has demonstrated excellent inter-rater reliability (ICC = 0.997) and intra-rater reliability (ICC = 0.924) and good internal consistency (Cronbach's alpha = 0.643 - 0.832) in people with dementia, mild cognitive impairment and healthy older adults.	Post-intervention (6 week)
Primary	Rivermead Behavioural Memory Test - Third edition	The Rivermead Behavioural Memory Test - Third edition (RBMT-3) examines the everyday memory function with 14 subtests, including the assessment for visual, verbal, recall, recognition, immediate, and delayed memory. The scaled score of each subtest and total scaled score will be computed by converting raw scores based on different age group. Higher scaled score indicates better memory function. The RBMT-3 has demonstrated excellent inter-rater reliability (ICC = 0.997) and intra-rater reliability (ICC = 0.924) and good internal consistency (Cronbach's alpha = 0.643 - 0.832) in people with dementia, mild cognitive impairment and healthy older adults.	1-month follow-up (10 week)
Primary	Digit Span Test	The Digit Span Test (DST) consists of two parts to measure the verbal short-term memory and working memory of an individual, which are digit span forwards and digit span backwards. The participants are presented with a series of numbers. In the digit span forward (DSF), they are required to repeat the numbers in forward order. In the digit span backward (DSB), they are asked to repeat the numbers in reverse order. The length of digits in each string increases from 3 to 9 in DSF and from 2 to 8 in DSB. Two trials are presented at each length. The test is interrupted when participant failed to either trial at equal digit length. If the participants correctly recall the sequence in either first and second trial, 1 point will be scored. The total score of DSF and DSB are 16 and 14 respectively. The intra-rater reliability of DSF and DSB are 0.891 and 0.598 respectively in older adults with neurocognitive disorder.	Baseline (0 week)
Primary	Digit Span Test	The Digit Span Test (DST) consists of two parts to measure the verbal short-term memory and working memory of an individual, which are digit span forwards and digit span backwards. The participants are presented with a series of numbers. In the digit span forward (DSF), they are required to repeat the numbers in forward order. In the digit span backward (DSB), they are asked to repeat the numbers in reverse order. The length of digits in each string increases from 3 to 9 in DSF and from 2 to 8 in DSB. Two trials are presented at each length. The test is interrupted when participant failed to either trial at equal digit length. If the participants correctly recall the sequence in either first and second trial, 1 point will be scored. The total score of DSF and DSB are 16 and 14 respectively. The intra-rater reliability of DSF and DSB are 0.891 and 0.598 respectively in older adults with neurocognitive disorder.	Mid-intervention (3 week)
Primary	Digit Span Test	The Digit Span Test (DST) consists of two parts to measure the verbal short-term memory and working memory of an individual, which are digit span forwards and digit span backwards. The participants are presented with a series of numbers. In the digit span forward (DSF), they are required to repeat the numbers in forward order. In the digit span backward (DSB), they are asked to repeat the numbers in reverse order. The length of digits in each string increases from 3 to 9 in DSF and from 2 to 8 in DSB. Two trials are presented at each length. The test is interrupted when participant failed to either trial at equal digit length. If the participants correctly recall the sequence in either first and second trial, 1 point will be scored. The total score of DSF and DSB are 16 and 14 respectively. The intra-rater reliability of DSF and DSB are 0.891 and 0.598 respectively in older adults with neurocognitive disorder.	Post-intervention (6 week)
Primary	Digit Span Test	The Digit Span Test (DST) consists of two parts to measure the verbal short-term memory and working memory of an individual, which are digit span forwards and digit span backwards. The participants are presented with a series of numbers. In the digit span forward (DSF), they are required to repeat the numbers in forward order. In the digit span backward (DSB), they are asked to repeat the numbers in reverse order. The length of digits in each string increases from 3 to 9 in DSF and from 2 to 8 in DSB. Two trials are presented at each length. The test is interrupted when participant failed to either trial at equal digit length. If the participants correctly recall the sequence in either first and second trial, 1 point will be scored. The total score of DSF and DSB are 16 and 14 respectively. The intra-rater reliability of DSF and DSB are 0.891 and 0.598 respectively in older adults with neurocognitive disorder.	1-month follow-up (10 week)
Primary	Montreal Cognitive Assessment	The Montreal Cognitive Assessment (MoCA) is a screening tool to detect cognitive impairment of an individual with a total score of 30. The MoCA assesses different cognitive domains, including executive functioning, immediate and delayed memory, visuospatial abilities, attention, working memory, language, and orientation to time and place. It can identify dementia from controls with a sensitivity of 92.3% and specificity of 91.8% with a cut-off score of 22.	Baseline (0 week)
Primary	Montreal Cognitive Assessment	The Montreal Cognitive Assessment (MoCA) is a screening tool to detect cognitive impairment of an individual with a total score of 30. The MoCA assesses different cognitive domains, including executive functioning, immediate and delayed memory, visuospatial abilities, attention, working memory, language, and orientation to time and place. It can identify dementia from controls with a sensitivity of 92.3% and specificity of 91.8% with a cut-off score of 22.	Mid-intervention (3 week)
Primary	Montreal Cognitive Assessment	The Montreal Cognitive Assessment (MoCA) is a screening tool to detect cognitive impairment of an individual with a total score of 30. The MoCA assesses different cognitive domains, including executive functioning, immediate and delayed memory, visuospatial abilities, attention, working memory, language, and orientation to time and place. It can identify dementia from controls with a sensitivity of 92.3% and specificity of 91.8% with a cut-off score of 22.	Post-intervention (6 week)
Primary	Montreal Cognitive Assessment	The Montreal Cognitive Assessment (MoCA) is a screening tool to detect cognitive impairment of an individual with a total score of 30. The MoCA assesses different cognitive domains, including executive functioning, immediate and delayed memory, visuospatial abilities, attention, working memory, language, and orientation to time and place. It can identify dementia from controls with a sensitivity of 92.3% and specificity of 91.8% with a cut-off score of 22.	1-month follow-up (10 week)
Primary	Trail Making Test	Trail Making Test (TMT) can assess the attention and cognitive flexibility of individuals. The test is divided into part A and part B. In part A, the circle is numbered (i.e., 1 to 25). The subjects should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L). The subjects should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). A shorter time recorded in the test indicated the better performance. The test-retest reliability has been tested in people with stroke (ICC = 0.94 and 0.86 for Part A and Part B, respectively).	Baseline (0 week)
Primary	Trail Making Test	Trail Making Test (TMT) can assess the attention and cognitive flexibility of individuals. The test is divided into part A and part B. In part A, the circle is numbered (i.e., 1 to 25). The subjects should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L). The subjects should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). A shorter time recorded in the test indicated the better performance. The test-retest reliability has been tested in people with stroke (ICC = 0.94 and 0.86 for Part A and Part B, respectively).	Mid-intervention (3 week)
Primary	Trail Making Test	Trail Making Test (TMT) can assess the attention and cognitive flexibility of individuals. The test is divided into part A and part B. In part A, the circle is numbered (i.e., 1 to 25). The subjects should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L). The subjects should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). A shorter time recorded in the test indicated the better performance. The test-retest reliability has been tested in people with stroke (ICC = 0.94 and 0.86 for Part A and Part B, respectively).	Post-intervention (6 week)
Primary	Trail Making Test	Trail Making Test (TMT) can assess the attention and cognitive flexibility of individuals. The test is divided into part A and part B. In part A, the circle is numbered (i.e., 1 to 25). The subjects should draw lines in numeric order of the listed circle. In part B, the circles include both numbers (i.e., 1 to 13) and words (i.e., A to L). The subjects should draw the lines in a specific sequence between number and word (i.e., 1 to A to 2 to B etc.). A shorter time recorded in the test indicated the better performance. The test-retest reliability has been tested in people with stroke (ICC = 0.94 and 0.86 for Part A and Part B, respectively).	1-month follow-up (10 week)
Primary	Oxford Participation and Activities Questionnaire	The 23-item Oxford Participation and Activities Questionnaire (Ox-PAQ) evaluates participation and activity levels based on the three domains of routine activities, social engagement, and emotional well-being. Each item is measured on a 5-point Likert scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = always). The higher scores represent greater difficulties with participation and activities. Good to excellent internal consistency (Cronbach's a = 0.81 - 0.96) and test-retest reliability (ICC = 0.83 - 0.96) have been shown for this instrument in people with motor neuron disease, multiple sclerosis, and Parkinson's disease.	Baseline (0 week)
Primary	Oxford Participation and Activities Questionnaire	The 23-item Oxford Participation and Activities Questionnaire (Ox-PAQ) evaluates participation and activity levels based on the three domains of routine activities, social engagement, and emotional well-being. Each item is measured on a 5-point Likert scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = always). The higher scores represent greater difficulties with participation and activities. Good to excellent internal consistency (Cronbach's a = 0.81 - 0.96) and test-retest reliability (ICC = 0.83 - 0.96) have been shown for this instrument in people with motor neuron disease, multiple sclerosis, and Parkinson's disease.	Mid-intervention (3 week)
Primary	Oxford Participation and Activities Questionnaire	The 23-item Oxford Participation and Activities Questionnaire (Ox-PAQ) evaluates participation and activity levels based on the three domains of routine activities, social engagement, and emotional well-being. Each item is measured on a 5-point Likert scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = always). The higher scores represent greater difficulties with participation and activities. Good to excellent internal consistency (Cronbach's a = 0.81 - 0.96) and test-retest reliability (ICC = 0.83 - 0.96) have been shown for this instrument in people with motor neuron disease, multiple sclerosis, and Parkinson's disease.	Post-intervention (6 week)
Primary	Oxford Participation and Activities Questionnaire	The 23-item Oxford Participation and Activities Questionnaire (Ox-PAQ) evaluates participation and activity levels based on the three domains of routine activities, social engagement, and emotional well-being. Each item is measured on a 5-point Likert scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = always). The higher scores represent greater difficulties with participation and activities. Good to excellent internal consistency (Cronbach's a = 0.81 - 0.96) and test-retest reliability (ICC = 0.83 - 0.96) have been shown for this instrument in people with motor neuron disease, multiple sclerosis, and Parkinson's disease.	1-month follow-up (10 week)
Primary	12-item Short-Form Survey (second version)	The 12-item Short-Form Survey (second version) (SF-12v2) will be used to measure the health-related quality of life of individuals. This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better quality of life. It has good internal consistency (Cronbach's alpha = 0.48 - 0.81) and test-retest reliability (ICC = 0.67 - 0.82) in healthy adults.	Baseline (0 week)
Primary	12-item Short-Form Survey (second version)	The 12-item Short-Form Survey (second version) (SF-12v2) will be used to measure the health-related quality of life of individuals. This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better quality of life. It has good internal consistency (Cronbach's alpha = 0.48 - 0.81) and test-retest reliability (ICC = 0.67 - 0.82) in healthy adults.	Mid-intervention (3 week)
Primary	12-item Short-Form Survey (second version)	The 12-item Short-Form Survey (second version) (SF-12v2) will be used to measure the health-related quality of life of individuals. This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better quality of life. It has good internal consistency (Cronbach's alpha = 0.48 - 0.81) and test-retest reliability (ICC = 0.67 - 0.82) in healthy adults.	Post-intervention (6 week)
Primary	12-item Short-Form Survey (second version)	The 12-item Short-Form Survey (second version) (SF-12v2) will be used to measure the health-related quality of life of individuals. This instrument contains eight domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, emotional role, and mental health. The total score ranges from 0 to 100, with a higher score indicating better quality of life. It has good internal consistency (Cronbach's alpha = 0.48 - 0.81) and test-retest reliability (ICC = 0.67 - 0.82) in healthy adults.	1-month follow-up (10 week)
Primary	Arm Activity Measure	The Arm Activity Measure (ArmA) is a 20-item questionnaire to assess the difficulties in passive and active upper limb tasks, where section A evaluates the passive function and section B evaluates the active function. It uses a 5-point Likert scale, ranging from 0 (no difficulty) to 4 (unable to do the task). The total score of section A and B are 32 and 52 respectively [59]. The higher score in ArmA indicates more difficulties experienced in activities when using upper limb. Good internal consistency (Cronbach's alpha = 0.85 - 0.96) has been shown in people with upper limb paresis.	Baseline (0 week)
Primary	Arm Activity Measure	The Arm Activity Measure (ArmA) is a 20-item questionnaire to assess the difficulties in passive and active upper limb tasks, where section A evaluates the passive function and section B evaluates the active function. It uses a 5-point Likert scale, ranging from 0 (no difficulty) to 4 (unable to do the task). The total score of section A and B are 32 and 52 respectively [59]. The higher score in ArmA indicates more difficulties experienced in activities when using upper limb. Good internal consistency (Cronbach's alpha = 0.85 - 0.96) has been shown in people with upper limb paresis.	Mid-intervention (3 week)
Primary	Arm Activity Measure	The Arm Activity Measure (ArmA) is a 20-item questionnaire to assess the difficulties in passive and active upper limb tasks, where section A evaluates the passive function and section B evaluates the active function. It uses a 5-point Likert scale, ranging from 0 (no difficulty) to 4 (unable to do the task). The total score of section A and B are 32 and 52 respectively [59]. The higher score in ArmA indicates more difficulties experienced in activities when using upper limb. Good internal consistency (Cronbach's alpha = 0.85 - 0.96) has been shown in people with upper limb paresis.	Post-intervention (6 week)
Primary	Arm Activity Measure	The Arm Activity Measure (ArmA) is a 20-item questionnaire to assess the difficulties in passive and active upper limb tasks, where section A evaluates the passive function and section B evaluates the active function. It uses a 5-point Likert scale, ranging from 0 (no difficulty) to 4 (unable to do the task). The total score of section A and B are 32 and 52 respectively [59]. The higher score in ArmA indicates more difficulties experienced in activities when using upper limb. Good internal consistency (Cronbach's alpha = 0.85 - 0.96) has been shown in people with upper limb paresis.	1-month follow-up (10 week)