The impact of aerobic and resistance training intensity on markers of neuroplasticity in health and disease

Physical exercise and synaptic protection in human and pre-clinical models of multiple sclerosis

In multiple sclerosis, only immunomodulatory and immunosuppressive drugs are recognized as disease-modifying therapies. However, in recent years, several data from pre-clinical and clinical studies suggested a possible role of physical exercise as disease-modifying therapy in multiple sclerosis. Current evidence is sparse and often conflicting, and the mechanisms underlying the neuroprotective and antinflammatory role of exercise in multiple sclerosis have not been fully elucidated. Data, mainly derived from pre-clinical studies, suggest that exercise could enhance long-term potentiation and thus neuroplasticity, could reduce neuroinflammation and synaptopathy, and dampen astrogliosis and microgliosis. In humans, most trials focused on direct clinical and MRI outcomes, as investigating synaptic, neuroinflammatory, and pathological changes is not straightforward compared to animal models. The present review analyzed current evidence and limitations in research concerning the potential disease-modifying therapy effects of exercise in multiple sclerosis in animal models and human studies.

Resistance training effects on healthy postmenopausal women: a systematic review with meta-analysis

The aim of this systematic review with meta-analysis was to evaluate the effects of resistance training on physical fitness, physiological variables and body composition of postmenopausal women. The present systematic review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and was registered in PROSPERO. A total of 12 studies were included. The literature search was performed in PubMed, Web of Science and EBSCO. Randomized control trials were included. Two blinded investigators performed the search, study selection and data collection, and assessed the quality and risk of bias. A random-effects model was used for all analyses. Compared to the control group, resistance training produced a significant improvement in maximal oxygen volume (standardized mean difference [SMD] = 2.32, p < 0.001), lower extremity strength (SMD = 4.70, p < 0.001) and upper extremity strength (SMD = 7.42, p < 0.001). The results obtained in the systematic review and meta-analysis confirm the benefits of resistance training on physical fitness in postmenopausal women, although there is more debate regarding its influence on bone mineral density, and anthropometric and derived variables. This work provides a solid starting point for promoting resistance training at a frequency of 3 days per week, in 60-min sessions, with the aim of improving parameters directly related to quality of life, functionality and disease prevention of postmenopausal women.

Physical exercise, cognition, and brain health in aging

Exercise training is an important strategy to counteract cognitive and brain health decline during aging. Evidence from systematic reviews and meta-analyses supports the notion of beneficial effects of exercise in cognitively unimpaired and impaired older individuals. However, the effects are often modest, and likely influenced by moderators such as exercise training parameters, sample characteristics, outcome assessments, and control conditions. Here, we discuss evidence on the impact of exercise on cognitive and brain health outcomes in healthy aging and in individuals with or at risk for cognitive impairment and neurodegeneration. We also review neuroplastic adaptations in response to exercise and their potential neurobiological mechanisms. We conclude by highlighting goals for future studies, including addressing unexplored neurobiological mechanisms and the inclusion of under-represented populations.

Randomized controlled trials of non-pharmacological interventions for healthy seniors: Effects on cognitive decline, brain plasticity and activities of daily living-A 23-year scoping review

Little is known about the simultaneous effects of non-pharmacological interventions (NPI) on healthy older adults' behavior and brain plasticity, as measured by psychometric instruments and magnetic resonance imaging (MRI). The purpose of this scoping review was to compile an extensive list of randomized controlled trials published from January 1, 2000, to August 31, 2023, of NPI for mitigating and countervailing age-related physical and cognitive decline and associated cerebral degeneration in healthy elderly populations with a mean age of 55 and over. After inventorying the NPI that met our criteria, we divided them into six classes: single-domain cognitive, multi-domain cognitive, physical aerobic, physical non-aerobic, combined cognitive and physical aerobic, and combined cognitive and physical non-aerobic. The ultimate purpose of these NPI was to enhance individual autonomy and well-being by bolstering functional capacity that might transfer to activities of daily living. The insights from this study can be a starting point for new research and inform social, public health, and economic policies. The PRISMA extension for scoping reviews (PRISMA-ScR) checklist served as the framework for this scoping review, which includes 70 studies. Results indicate that medium- and long-term interventions combining non-aerobic physical exercise and multi-domain cognitive interventions best stimulate neuroplasticity and protect against age-related decline and that outcomes may transfer to activities of daily living.

Activity in the pontine reticular nuclei scales with handgrip force in humans

The neural pathways that contribute to force production in humans are currently poorly understood, as the relative roles of the corticospinal tract and brainstem pathways, such as the reticulospinal tract (RST), vary substantially across species. Using functional magnetic resonance imaging (fMRI), we aimed to measure activation in the pontine reticular nuclei (PRN) during different submaximal handgrip contractions to determine the potential role of the PRN in force modulation. Thirteen neurologically intact participants (age: 28 ± 6 yr) performed unilateral handgrip contractions at 25%, 50%, 75% of maximum voluntary contraction during brain scans. We quantified the magnitude of PRN activation from the contralateral and ipsilateral sides during each of the three contraction intensities. A repeated-measures ANOVA demonstrated a significant main effect of force (P = 0.012, [Formula: see text] = 0.307) for PRN activation, independent of side (i.e., activation increased with force for both contralateral and ipsilateral nuclei). Further analyses of these data involved calculating the linear slope between the magnitude of activation and handgrip force for each region of interest (ROI) at the individual-level. One-sample t tests on the slopes revealed significant group-level scaling for the PRN bilaterally, but only the ipsilateral PRN remained significant after correcting for multiple comparisons. We show evidence of task-dependent activation in the PRN that was positively related to handgrip force. These data build on a growing body of literature that highlights the RST as a functionally relevant motor pathway for force modulation in humans.NEW & NOTEWORTHY In this study, we used a task-based functional magnetic resonance imaging (fMRI) paradigm to show that activity in the pontine reticular nuclei scales linearly with increasing force during a handgrip task. These findings directly support recently proposed hypotheses that the reticulospinal tract may play an important role in modulating force production in humans.

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Physical activity may a probably protective factor for postoperative delirium: the PNDABLE study

Objective

This study aims to explore the relationship between physical activity (PA) and postoperative delirium (POD).

Methods

We selected 400 patients from the Perioperative Neurocognitive Disorder and Biomarkers Lifestyle (PNDABLE) database, and the patients in the PNDABLE database were sampled and tested Alzheimer's biomarkers. The diagnosis of POD was made using the Confusion Assessment Scale (CAM) and the severity was assessed using Memorial Delirium Assessment Scale (MDAS). Mini-Mental State Examination (MMSE) scale was used to detect the mental state of the patients. Enzyme-linked immunosorbent assay (ELISA) was used to detect the level of preoperative cerebrospinal fluid (CSF) biomarkers, such as amyloid β plaque 42 (Aβ42), total tau protein (T-tau), and phosphorylated tau protein (P-tau). Logistic regression, sensitivity analysis, and post hoc analysis were used to explore the relationship between risk and protective factors on POD. We used the mediating effect to explore whether PA mediates the occurrence of POD through CSF biomarkers.

Results

The incidence of POD was 17.5%. According to our research, the consequence prompted that PA might be the protective factor for POD [odds ratio (OR): 0.336, 95% confidence interval (95 CI) 0.206-0.548, P < 0.001]. The result of logistic regression revealed that CSF biomarker Aβ42 (OR: 0.997, 95 CI 0.996-0.999, P < 0.001) might be a protective factor against POD, and the T-tau (OR: 1.006, 95 CI 1.003-1.009, P = 0.001) and P-tau (OR: 1.039, 95 CI 1.018-1.059, P < 0.001) might risk factors for POD. Sensitivity analysis confirmed the correlation between PA and CSF biomarkers in the patients with POD. Mediation effect analysis showed that PA may reduce the occurrence of POD partly through CSF biomarkers, such as Aβ42 (proportion: 11%, P < 0.05), T-tau (proportion: 13%, P < 0.05), and P-tau (proportion: 12%, P < 0.05).

Conclusion

Physical activity is probably a protective factor for POD and may exert a mediating effect through CSF biomarkers.

Aerobic exercise training effects on hippocampal volume in healthy older individuals: a meta-analysis of randomized controlled trials

We conducted a meta-analysis of randomized controlled trials investigating the effects of aerobic exercise training (AET) lasting ≥ 4 weeks on hippocampal volume and cardiorespiratory fitness (CRF) in cognitively unimpaired, healthy older individuals. Random-effects robust variance estimation models were used to test differences between AET and controls, while meta-regressions tested associations between CRF and hippocampal volume changes. We included eight studies (N = 554) delivering fully supervised AET for 3 to 12 months (M = 7.8, SD = 4.5) with an average AET volume of 129.85 min/week (SD = 45.5) at moderate-to-vigorous intensity. There were no significant effects of AET on hippocampal volume (SMD = 0.10, 95% CI - 0.01 to 0.21, p = 0.073), but AET moderately improved CRF (SMD = 0.30, 95% CI 0.12 to 0.48, p = 0.005). Improvement in CRF was not associated with changes in hippocampal volume (bSE = 0.05, SE = 0.51, p = 0.923). From the limited number of studies, AET does not seem to impact hippocampal volume in cognitively unimpaired, healthy older individuals. Notable methodological limitations across investigations might mask the lack of effects.

Changes in EEG Activity and Cognition Related to Physical Activity in Older Adults: A Systematic Review

Aging is generally associated with a decline in important cognitive functions that can be observed in EEG. Physical activity in older adults should be considered one of the main strategies to promote health and prevent disease in the elderly. The present study aimed to systematically review studies of EEG activity and cognitive function changes associated with physical activity in older adults. Records from PubMed, Scopus, and EBSCO databases were searched and, following the PRISMA guidelines, nine studies were included in the present systematic review. A risk of bias assessment was performed using the National Institute of Health Quality Assessment Tool for Case-control Studies instrument. The studies analyzed used two main strategies to determine the effects of physical activity on cognition and EEG: (1) multiscale entropy and power frequencies; and (2) event-related potentials. In terms of EEG activity, it can be concluded that exercise-induced neuroplasticity underlies improvements in cognitive function in healthy older adults.

Exercise Made Accessible: the Merits of Community-Based Programs for Persons with Parkinson's Disease

PURPOSE OF REVIEW

Many studies have identified positive effects of physiotherapy and exercise for persons with Parkinson's disease (PD). Most work has thus far focused on the therapeutic modality of exercise as used within physiotherapy programs. Stimulated by these positive findings, there is now a strong move to take exercise out of the clinical setting and to deliver the interventions in the community. Although the goals and effects of many such community-based exercise programs overlap with those of physiotherapy, it has also become more clear that both exercise modalities also differ in various ways. Here, we aim to comprehensively review the evidence for community-based exercise in PD.

RECENT FINDINGS

Many different types of community-based exercise for people with PD are emerging and they are increasingly being studied. There is a great heterogeneity considering the types of exercise, study designs, and outcome measures used in research on this subject. While this review is positive regarding the feasibility and potential effects of community-based exercise, it is also evident that the general quality of these studies needs improvement. By focusing on community-based exercise, we hope to generate more knowledge on the effects of a wide range of different exercise modalities that can be beneficial for people with PD. This knowledge may help people with PD to select the type and setting of exercise activity that matches best with their personal abilities and preferences. As such, these insights will contribute to an improved self-management of PD.

Cognitive functions and sense of coherence in patients with carotid artery stenosis-Preliminary report

Background

There is scarcely any data in the available literature on the relationship between sense of coherence (SOC) and cognitive functioning, and no information on the relationship between SOC and cognitive parameters in patients with carotid atherosclerosis.

Aim

The aim of this paper was to determine the relationship of SOC measured prior to carotid artery stenting (CAS) with neurocognitive functioning in patients with carotid atherosclerosis 12 months after CAS.

Methods

A total of 35 patients with carotid atherosclerosis completed the SOC-29 Orientation to Life Questionnaire (SOC-29) and completed a cognitive test battery twice, i.e., before (baseline-T1) and 12 months after stent implantation (follow-up-T2). Selected cognitive functions such as memory, attention, perception, visuospatial and executive functions and non-verbal fluency were assessed.

Results

One year after the procedure, patients with a higher SOC and sense of manageability present better performance in visual memory. Higher SOC and sense of meaningfulness are positively related to the speed of understanding the changing rules of card sorting (WCST).

Conclusion

Higher overall SOC and a component of sense of meaningfulness and manageability may be related to better cognitive functioning 1 year after the procedure.

Moderate Intensity of Treadmill Exercise Rescues TBI-Induced Ferroptosis, Neurodegeneration, and Cognitive Impairments via Suppressing STING Pathway

Traumatic brain injury (TBI) is a universal leading cause of long-term neurological disability and causes a huge burden to an ever-growing population. Moderate intensity of treadmill exercise has been recognized as an efficient intervention to combat TBI-induced motor and cognitive disorders, yet the underlying mechanism is still unclear. Ferroptosis is known to be highly implicated in TBI pathophysiology, and the anti-ferroptosis effects of treadmill exercise have been reported in other neurological diseases except for TBI. In addition to cytokine induction, recent evidence has demonstrated the involvement of the stimulator of interferon genes (STING) pathway in ferroptosis. Therefore, we examined the possibility that treadmill exercise might inhibit TBI-induced ferroptosis via STING pathway. In this study, we first found that a series of ferroptosis-related characteristics, including abnormal iron homeostasis, decreased glutathione peroxidase 4 (Gpx4), and increased lipid peroxidation, were detected at 44 days post TBI, substantiating the involvement of ferroptosis at the chronic stage following TBI. Furthermore, treadmill exercise potently decreased the aforementioned ferroptosis-related changes, suggesting the anti-ferroptosis role of treadmill exercise following TBI. In addition to alleviating neurodegeneration, treadmill exercise effectively reduced anxiety, enhanced spatial memory recovery, and improved social novelty post TBI. Interestingly, STING knockdown also obtained the similar anti-ferroptosis effects after TBI. More importantly, overexpression of STING largely reversed the ferroptosis inactivation caused by treadmill exercise following TBI. To conclude, moderate-intensity treadmill exercise rescues TBI-induced ferroptosis and cognitive deficits at least in part via STING pathway, broadening our understanding of neuroprotective effects induced by treadmill exercise against TBI.

Resistance Training Maintains White Matter and Physical Function in Older Women with Cerebral Small Vessel Disease: An Exploratory Analysis of a Randomized Controlled Trial

Background

As the aging population grows, there is an increasing need to develop accessible interventions against risk factors for cognitive impairment and dementia, such as cerebral small vessel disease (CSVD). The progression of white matter hyperintensities (WMHs), a key hallmark of CSVD, can be slowed by resistance training (RT). We hypothesize RT preserves white matter integrity and that this preservation is associated with improved cognitive and physical function.

Objective

To determine if RT preserves regional white matter integrity and if any changes are associated with cognitive and physical outcomes.

Methods

Using magnetic resonance imaging data from a 12-month randomized controlled trial, we compared the effects of a twice-weekly 60-minute RT intervention versus active control on T1-weighted over T2-weighted ratio (T1w/T2w; a non-invasive proxy measure of white matter integrity) in a subset of study participants (N = 21 females, mean age = 69.7 years). We also examined the association between changes in T1w/T2w with two key outcomes of the parent study: (1) selective attention and conflict resolution, and (2) peak muscle power.

Results

Compared with an active control group, RT increased T1w/T2w in the external capsule (p = 0.024) and posterior thalamic radiations (p = 0.013) to a greater degree. Increased T1w/T2w in the external capsule was associated with an increase in peak muscle power (p = 0.043) in the RT group.

Conclusion

By maintaining white matter integrity, RT may be a promising intervention to counteract the pathological changes that accompany CSVD, while improving functional outcomes such as muscle power.

Physical activity and the brain myelin content in humans

New imaging sequences and biophysical models allow adopting magnetic resonance imaging (MRI) for in vivo myelin mapping in humans. Understanding myelination and remyelination processes in the brain is fundamental from the perspective of proper design of physical exercise and rehabilitation schemes that aim to slow down demyelination in the aging population and to induce remyelination in patients with neurodegenerative diseases. Therefore, in this review we strive to provide a state-of-the art summary of the existing MRI studies in humans focused on the effects of physical activity on myelination/remyelination. We present and discuss four cross-sectional and four longitudinal studies and one case report. Physical activity and an active lifestyle have a beneficial effect on the myelin content in humans. Myelin expansion can be induced in humans throughout the entire lifespan by intensive aerobic exercise. Additional research is needed to determine (1) what exercise intensity (and cognitive novelty, which is embedded in the exercise scheme) is the most beneficial for patients with neurodegenerative diseases, (2) the relationship between cardiorespiratory fitness and myelination, and (3) how exercise-induced myelination affect cognitive abilities.

Clinical Trial Highlights - Interventions Promoting Physical Activity in Parkinson's Disease

Despite increasing evidence on exercise in Parkinson's disease (PD) it remains unclear what type and intensity of exercise are most effective. Currently, most evidence favors moderate- to high-intensity aerobic exercise for its positive effects on motor symptoms as well as disease modifying potential. On the other hand, observational studies have shown that the sheer volume of exercise matters as well, independent of intensity. So far, the efficacy of the volume of exercise has not been confirmed by randomized controlled trials (RCTs). Here, we provide an overview of the ongoing RCTs that promote physical activity in daily life in PD. We found seven RCTs with sample sizes between 30 and 452 and a follow-up between 4 weeks and 12 months. Steps per day is the most commonly reported primary outcome measure. The ongoing RCTs will provide evidence for feasibility, whereafter the PD research field is ready for a next step and to explore the effect of physical activity on disease progression and PD symptoms.

No strong association among epigenetic modifications by DNA methylation, telomere length, and physical fitness in biological aging

Cellular senescence is greatly accelerated by telomere shortening, and the steps forward in human aging are strongly influenced by environmental and lifestyle factors, whether DNA methylation (DNAm) is affected by exercise training, remains unclear. In the present study, we investigated the relationships between physiological functions, maximal oxygen uptake (VO2max), vertical jump, working memory, telomere length (TL) assessed by RT-PCR, DNA methylation-based estimation of TL (DNAmTL), and DNA methylation-based biomarkers of aging of master rowers (N = 146) and sedentary subjects (N = 95), aged between 37 and 85 years. It was found that the TL inversely correlated with chronological age. We could not detect an association between telomere length and VO2max, vertical jump, and working memory by RT-PCR method, while these physiological test results showed a correlation with DNAmTL. DNAmGrimAge and DNAmPhenoAge acceleration were inversely associated with telomere length assessed by both methods. It appears that there are no strong beneficial effects of exercise or physiological fitness on telomere shortening, however, the degree of DNA methylation is associated with telomere length.

Effects of 2-Year-Long Maintenance Training and Detraining on 558 Subacute Ischemic Stroke Patients' Clinical-Motor Symptoms

PURPOSE

This study aimed to determine the effects of a 2-yr-long maintenance training (MT) exergaming and detraining (DT) on clinical-motor symptoms in subacute ischemic patients with stroke (PwST). The hypothesis was that MT motor rehabilitation program would further increase the effects of the initial rehabilitation.

METHODS

After high-intensity and high-frequency exergaming twice or once a day, 5 times per week for 5 wk (EX2: 50 sessions; EX1: 25 sessions, results reported previously), 558 PwST were randomized to EX2-MT, EX2-DT, EX1-MT, and EX1-DT. MT exergaming consisted of once a day, 3 times per week for 2 yr, and DT did not train. Outcomes were measured at 6, 12, 18, and 24 months. The data were analyzed using longitudinal linear mixed-effects models and general linear hypotheses testing.

RESULTS

Modified Rankin Score (primary outcome), body mass, Mini-Mental State Examination score, Beck Depression Inventory, measures of quality of life, Berg Balance Scale, 6-min walk test, and four measures of center of pressure path tended to retain the initial rehabilitation-induced gains in the MT patients in selected outcomes (especially walking capacity). The scores tended to mildly worsen after DT, partially supporting the hypothesis.

CONCLUSIONS

MT successfully maintained, but only in selected variables did it further increase the initial exergaming rehabilitation-induced robust improvements. DT modestly reduced the initial exergaming rehabilitation-induced improvements. MT programs might be needed after initial stroke rehabilitation to reduce subsequent losses of quality of life and further improve clinical-motor symptoms.

Age-related changes in gait biomechanics and their impact on the metabolic cost of walking: Report from a National Institute on Aging workshop

Changes in old age that contribute to the complex issue of an increased metabolic cost of walking (mass-specific energy cost per unit distance traveled) in older adults appear to center at least in part on changes in gait biomechanics. However, age-related changes in energy metabolism, neuromuscular function and connective tissue properties also likely contribute to this problem, of which the consequences are poor mobility and increased risk of inactivity-related disease and disability. The U.S. National Institute on Aging convened a workshop in September 2021 with an interdisciplinary group of scientists to address the gaps in research related to the mechanisms and consequences of changes in mobility in old age. The goal of the workshop was to identify promising ways to move the field forward toward improving gait performance, decreasing energy cost, and enhancing mobility for older adults. This report summarizes the workshop and brings multidisciplinary insight into the known and potential causes and consequences of age-related changes in gait biomechanics. We highlight how gait mechanics and energy cost change with aging, the potential neuromuscular mechanisms and role of connective tissue in these changes, and cutting-edge interventions and technologies that may be used to measure and improve gait and mobility in older adults. Key gaps in the literature that warrant targeted research in the future are identified and discussed.

Influences of Aerobic Exercise on Motor Sequence Learning and Corticomotor Excitability in People With Parkinson's Disease

BACKGROUND

People with Parkinson's disease (PD) are known to have motor learning difficulties. Although numerous studies have demonstrated that a single bout of aerobic exercise (AEX) can facilitate motor learning in non-disabled adults, the same beneficial effect in PD is unknown. Furthermore, associated neuroplastic changes have not been investigated.

OBJECTIVES

This study aimed to determine whether a single bout of aerobic exercise (AEX) can facilitate motor sequence learning in people with PD and to investigate the associated neurophysiological changes.

METHODS

Thirty individuals with PD were recruited and randomized into the exercise group (PD + AEX) and non-exercise group (PD - AEX). At the first visit, corticomotor excitability was assessed using transcranial magnetic stimulation (TMS). All participants then performed a serial reaction time task (SRTT) followed by 20 minutes of moderately-high intensity aerobic exercise (AEX) for the PD + AEX group or rest for the PD - AEX group. The SRTT and TMS were reevaluated at 3 time points: immediately after aerobic exercise (AEX) or rest, on the second day after practice (D2), and a week after practice (D7).

RESULTS

Both groups showed improvement throughout practice. At retention, the PD + AEX group showed improved SRTT performance on D7 compared to D2 (P = .001), while the PD - AEX group showed no change in performance. TMS results showed that the PD + AEX group had significantly higher corticomotor excitability than the PD - AEX group on D7.

CONCLUSION

A single session of aerobic exercise (AEX) could enhance motor sequence learning and induce neuroplastic changes. Clinicians can consider providing aerobic exercise (AEX) after motor task training for people with PD.

CLINICAL REGISTRATION

NCT04189887 (ClinicalTrials.gov).

Clinical Trial Highlights - Aerobic Exercise for Parkinson's Disease

Converging lines of evidence suggest that aerobic exercise impacts Parkinson's disease (PD) motor symptoms and might slow it's progression. We provide an overview of the ongoing randomized clinical trials (RCTs) on aerobic exercise in PD. We found six RCTs with sample sizes between 28 and 370 and a follow-up between 8 weeks and 18 months. PD motor symptoms is mostly used as primary outcome while various secondary outcomes are reported. We need more trials that use both clinical endpoints and markers of neuroplasticity, and provide insight into the optimal exercise mode, duration and intensity.