Neurocognitive Plasticity Is Associated with Cardiorespiratory Fitness Following Physical Exercise in Older Adults with Amnestic Mild Cognitive Impairment

Mapping the scientific research on exercise therapy for Alzheimer's disease: a scientometric study of hotspots and emerging trends

Background

Alzheimer's disease (AD) is the most common form of dementia globally, placing a substantial economic burden on patients and society. Exercise serves as an adjuvant therapy for AD with a low incidence of related adverse events. As a non-pharmacological intervention, it has demonstrated significant potential in the therapy of AD.

Objective

This study examines the key hotspots and emerging trends in exercise therapy for AD, offering valuable insights for researchers engaged in future research in this field.

Methods

The Web of Science Core Collection database was utilized to search for literature on exercise therapy for AD from January 1, 2000, to November 1, 2024, with 1,372 relevant articles being identified. And CiteSpace 6.2.R4 and VOSviewer were used to evaluate the bibliometric indicators.

Results

Since 2000, the number of publications in the field of exercise therapy for AD has been increasing. In addition to the well-known areas of research, such as the impact of exercise on cognitive function, the combination of exercise and medication therapy, the effects of exercise on specific symptoms, and the exercise with music therapy, the field may also focus on more novel topics. These include the integration of the design and implementation of exercise interventions, exercise and dendritic spines, and exercise and neurophysiological mechanisms. Furthermore, an analysis of emerging keywords reveals that the current main research direction is exploring the specific physiological mechanisms through which exercise affects AD. This includes three emerging trends: the impact of exercise on cognitive impairment in AD patients, the effects of exercise on brain-derived neurotrophic factor (BDNF) and Amyloid beta, and the influence of exercise on Stress and neuroinflammation.

Conclusion

The research results indicate that interventions using exercise to alleviate the negative symptoms of AD, as well as combining exercise with medication for therapy, are gaining increasing attention from researchers. Meanwhile, novel topics such as exercise and music therapy, the design and implementation of exercise interventions, and neurophysiological mechanisms should also attract scholarly interest. Additionally, exploring the physiological mechanisms behind exercise therapy for AD could be a key focus for future research.

Neural mechanisms of non-pharmacological interventions in patients with mild cognitive impairment and Alzheimer's disease: An ALE meta-analysis

Non-pharmacologic interventions are effective for persons showing mild cognitive impairment (MCI) and Alzheimer's disease (AD). We used activation likelihood estimation (ALE) meta-analysis to systematically quantify the results of 19 neuroimaging studies in order to identify brain regions in which patients showed stable increases or decreases in activation after interventions. We also tested the moderating effects of disease stage (MCI vs. AD) and intervention modality (cognitive training vs. exercise intervention). The results showed increased activation in the cuneus, precuneus and medial frontal gyrus in the combined groups after treatment, whereas the anterior cingulate gyrus showed decreased activation. Secondly, in the MCI group there was increased activation in the precuneus and precentral gyrus after treatment, whereas there was decreased activation in the anterior cingulate gyrus; in the AD group there was only increased activation after treatment, including in the lingual gyrus and bilateral superior temporal gyrus. Finally, the bilateral cuneus and precentral gyrus showed increased activation after cognitive training, while bilateral insula, among others, showed decreased activation. This suggests that there are brain activation changes after non-pharmacological treatments for MCI and AD patients, but that the treatment mechanisms are moderated by stage and intervention modality. Future studies could continue to explore specific neural mechanisms involved in different intervention conditions for these patients.

The neural correlates of physical exercise-induced general cognitive gains: A systematic review and meta-analysis of functional magnetic resonance imaging studies

The general-domain effect of physical exercise-induced cognitive gains in behavioral outcomes is well-documented, but a consensus on the neural correlates remains elusive. This meta-analysis aims to identify the neural correlates of physical exercise-induced general cognitive gains by examining task-related brain activation consistently modulated by physical exercise and its relationship to those gains. Our analysis of 52 studies with 1503 participants shows that physical exercise enhances cognitive task performance (Hedges' g = 0.271) and consistently increases task-related brain activation primarily in the bilateral precuneus. These increases in task-related brain activation correlate positively with cognitive task performance improvements improvements. Notably, physical exercise intensity, adherence, and social environment significantly modulate task-related brain activation changes induced by physical exercise. This meta-analysis offers an unprecedented comprehensive assessment of how physical exercise modulates task-related brain activation changes, providing neural evidence to support the general-domain effects on cognitive function induced by physical exercise.

Effect of a Multicomponent Exercise Intervention on Recovery of Walking Ability in Stroke Survivors: A Systematic Review With Meta-analysis

OBJECTIVE

To evaluate whether multicomponent exercise (MCE) is more effective than single exercise in improving walking ability in patients with stroke.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

A systematic search of PubMed, Embase, Web of Science, Cochrane Library, and CINAHL from the establishment of each database to February 2024 was performed. A combination of medical subject headings and free-text terms relating to stroke and exercise were searched.

STUDY SELECTION

Randomized controlled trials treating stroke survivors with MCE were included. The control groups received conventional treatments such as conventional treatment or no intervention or sham training; the experimental groups received MCE. The outcome measures were walking endurance, gait speed, and balance ability.

DATA EXTRACTION

The data extraction form was completed by 2 independent reviewers. The risk of bias was assessed using the Cochrane Risk of Bias Tool for randomized controlled trials. Review manager 5.4 software was used for data analysis. Subgroup analysis and sensitivity analysis were used to supplement the results with higher heterogeneity. The preferred reporting project for systematic reviews and meta-analyses 2020 guidelines were followed.

DATA SYNTHESIS

Twelve studies were included. Meta-analyses found that compared with the control group, the MCE significantly affected gait speed (mean difference=0.11; 95% CI, 0.06-0.16; I2=0%), but the effect on balance ability was not statistically significant. Subgroup analysis showed that MCE (≥60min) was effective in improving walking endurance. These results suggest that MCE improves walking endurance and walking speed in patients with stroke.

CONCLUSIONS

MCE helps improve the gait speed of stroke survivors. Prolonging the MCE time may have a better effect on improving the walking endurance of patients with stroke.

Exercise intervention on the brain structure and function of patients with mild cognitive impairment: systematic review based on magnetic resonance imaging studies

Objective

This systematic review evaluates the impact of exercise intervention in MCI patients and discusses the potential neural mechanisms.

Methods

A systematic search and screening of relevant literature was conducted in English and Chinese databases. Based on predefined keywords and criteria, 24 articles were assessed and analyzed.

Results

Structurally, a significant increase was observed in the hippocampal and gray matter volumes of MCI patients following exercise intervention, with a trend of improvement in cortical thickness and white matter integrity. Functionally, after the exercise intervention, there were significant changes in the local spontaneous brain activity levels, cerebral blood flow, and functional connectivity during rest and memory encoding and retrieval tasks in MCI patients.

Conclusion

Exercise may contribute to delaying neurodegenerative changes in brain structure and function in patients with MCI. However, the underlying neural mechanisms require further research.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023482419.

Distinct medical and substance use histories associate with cognitive decline in Alzheimer's Disease

INTRODUCTION

Phenotype clustering reduces patient heterogeneity and could be useful when designing precision clinical trials. We hypothesized that the onset of early cognitive decline in patients would exhibit variance predicated on the clinical history documented prior to an Alzheimer's Disease (AD) diagnosis.

METHODS

Self-reported medical and substance use history (i.e., problem history) was used to cluster participants from the National Alzheimer's Coordinating Centers (NACC) into distinct subtypes. Linear mixed effects modeling was used to determine the effect of problem history subtype on cognitive decline over two years.

RESULTS

2754 individuals were partitioned into three subtypes: minimal (n = 1380), substance use (n = 1038), and cardiovascular (n = 336) subtypes. The cardiovascular problem history subtype had significantly worse cognitive decline over a two-year follow-up period (p = 0.013).

DISCUSSION

Our study highlights the need to account for problem history to reduce heterogeneity of outcomes in AD clinical trials.

Cardiorespiratory Fitness Assessment for Exercise Research in Mild Cognitive Impairment Due to Alzheimer's Disease

PURPOSE

To analyze cardiorespiratory fitness (CRF) levels using the gold-standard, laboratory-based cardiopulmonary exercise test (CPET) in community-dwelling older adults (N = 145) with amnestic mild cognitive impairment (aMCI), specifically CPET feasibility, CRF prediction, and CRF status in comparison to published sedentary, cognitively normal, age- and sex-adjusted normative data.

METHOD

Peak oxygen consumption (VO2Peak [mL/kg/min]) was assessed by CPET, which was categorized as submaximal, near-maximal, or maximal tests. VO2Max predicted was compared to VO2Max measured to assess its utility. Data were analyzed with t tests.

RESULTS

Participants' mean age was 73.77 years (SD = 5.74 years), with 51.7% males, 91.7% Caucasian, 68.3% married, and 16.9 years (SD = 2.88 years) of education. Mean VO2Peak measured was 17.07 (SD = 4.92) for the total sample (18.29 [SD = 4.64] for males, 15.78 [SD = 4.91] for females). Sixteen (11.03%) CPETs were submaximal, 53 (36.55%) were near-maximal, and 76 (52.41%) were maximal. Mean VO2Max predicted was 28.59 (SD = 21.94) for the total sample (29.36 [SD = 22.3] for males, 27.76 [SD = 21.68] for females) and was significantly higher than VO2Max measured (p < 0.0001). Among participants with maximal CPETs, VO2Peak measured was significantly lower than sedentary normative data (p < 0.0001).

CONCLUSION

CPET was feasible for older adults with aMCI. VO2Max predicted overly inflates CRF estimates. Low levels of CRF in older adults with aMCI suggest aerobic exercise as an important intervention. [Journal of Gerontological Nursing, 50(9), 31-36.].

Overlooked cases of mild cognitive impairment: Implications to early Alzheimer's disease

Mild cognitive impairment (MCI) marks the initial phase of memory decline or other cognitive functions like language or spatial perception, while individuals typically retain the capacity to carry out everyday tasks independently. Our comprehensive article investigates the intricate landscape of cognitive disorders, focusing on MCI and Alzheimer's disease (AD) and Alzheimer's disease-related dementias (ADRD). The study aims to understand the signs of MCI, early Alzheimer's disease, and healthy brain aging while assessing factors influencing disease progression, pathology development and susceptibility. A systematic literature review of over 100 articles was conducted, emphasizing MCI, AD and ADRD within the elderly populations. The synthesis of results reveals significant findings regarding ethnicity, gender, lifestyle, comorbidities, and diagnostic tools. Ethnicity was found to influence MCI prevalence, with disparities observed across diverse populations. Gender differences were evident in cognitive performance and decline, highlighting the need for personalized management strategies. Lifestyle factors and comorbidities were identified as crucial influencers of cognitive health. Regarding diagnostic tools, the Montreal Cognitive Assessment (MoCA) emerged as superior to the Mini-Mental State Examination (MMSE) in early MCI detection. Overall, our article provides insights into the multifaceted nature of cognitive disorders, emphasizing the importance of tailored interventions and comprehensive assessment strategies for effective cognitive health management.

Relations Between Cardiorespiratory Fitness and Cognition in Older Adults With Amnestic Mild Cognitive Impairment From the Aerobic Exercise and Cognitive Training (ACT) Trial: Sex Differences

Objective

To examine the associations of cardiorespiratory fitness with executive function, episodic memory, and global cognition and sex differences in these associations in community-dwelling older adults with amnestic mild cognitive impairment.

Design

A cross-sectional study using baseline data from the aerobic exercise and cognitive training (ACT) trial.

Setting

The ACT trial conducted exercise testing in an exercise laboratory and data collections in a research facility.

Participants

ACT trial participants were recruited through referrals, registries, exhibits, flyers, media, and advertisements and screened for eligibility. To be eligible for this study, ACT enrollees needed complete data on all study variables. Among 146 ACT enrollees, 142 met eligibility for this study (N=142).

Interventions

None.

Main Outcome Measures

Cardiorespiratory fitness was measured as peak oxygen consumption (Vo2peak) with a peak cycle-ergometer test, executive function with the EXAMINER, episodic memory with the Brief Visuospatial Memory Test-Revised, and global cognition with Montreal Cognitive Assessment.

Results

The average age of the sample was 73.8±5.8 years with 16.9±2.9 years of education, with 87.3% White, 51.4% men, and 69.7% married. After controlling for covariates, Vo2peak was significantly related to executive function (b=.037, standard error [SE]=0.015, P=.0154, semipartial [sr] correlation coefficient=.239) and episodic memory (b=.590, SE=0.226, P=.0102, sr=.216), but not global cognition (b=.074, SE=0.055, P=.1837, sr=.125). For men, Vo2peak was significantly associated with executive function (b=.063, SE=0.024, P=.0099, r=.430) and episodic memory (b=1.088, SE=0.312, P=.0009, r=.382).

Conclusions

Our findings show that Vo2peak was associated with executive function and episodic memory in the overall sample and in men. Future studies can examine the longitudinal relations between cardiorespiratory fitness and cognition.

Microbiota-gut-brain axis: the mediator of exercise and brain health

The brain controls the nerve system, allowing complex emotional and cognitive activities. The microbiota-gut-brain axis is a bidirectional neural, hormonal, and immune signaling pathway that could link the gastrointestinal tract to the brain. Over the past few decades, gut microbiota has been demonstrated to be an essential component of the gastrointestinal tract that plays a crucial role in regulating most functions of various body organs. The effects of the microbiota on the brain occur through the production of neurotransmitters, hormones, and metabolites, regulation of host-produced metabolites, or through the synthesis of metabolites by the microbiota themselves. This affects the host's behavior, mood, attention state, and the brain's food reward system. Meanwhile, there is an intimate association between the gut microbiota and exercise. Exercise can change gut microbiota numerically and qualitatively, which may be partially responsible for the widespread benefits of regular physical activity on human health. Functional magnetic resonance imaging (fMRI) is a non-invasive method to show areas of brain activity enabling the delineation of specific brain regions involved in neurocognitive disorders. Through combining exercise tasks and fMRI techniques, researchers can observe the effects of exercise on higher brain functions. However, exercise's effects on brain health via gut microbiota have been little studied. This article reviews and highlights the connections between these three interactions, which will help us to further understand the positive effects of exercise on brain health and provide new strategies and approaches for the prevention and treatment of brain diseases.

Brain function effects of exercise interventions for cognitive decline: a systematic review and meta-analysis

Introduction

Exercise is recognized as a modifiable lifestyle factor that can mitigate cognitive decline and dementia risk. While the benefits of exercise on cognitive aging have been reported on extensively, neuronal effects in adults experiencing cognitive decline have not been systematically synthesized. The aim of this systematic review was to assess the effects of exercise on cognition and brain function in people with cognitive decline associated with dementia risk.

Method

A systematic search was conducted for randomized controlled trials of ≥ 4 weeks exercise (aerobic, resistance, or mind-body) that assessed cognition and brain function using neuroimaging and neurophysiological measures in people with subjective or objective cognitive decline. Study characteristics and brain function effects were narratively synthesized, while domain-specific cognitive performance was subjected to meta-analysis. Study quality was also assessed.

Results

5,204 records were identified and 12 unique trials met the eligibility criteria, representing 646 adults classified with cognitive frailty, mild or vascular cognitive impairment. Most interventions involved 40-minute sessions conducted 3 times/week. Exercise improved global cognition (g = -0.417, 95% CI, -0.694 to -0.140, p = 0.003, I2 = 43.56%), executive function (g = -0.391, 95% CI, -0.651 to -0.131, p = 0.003, I2 = 13.28%), but not processing speed or general short-term memory (both p >0.05). Across fMRI and ERP studies, significant neuronal adaptations were found with exercise cf. control throughout the brain and were linked with improved global cognition, memory, and executive function. Cerebral blood flow was also found to improve with 24 weeks of exercise, but was not linked with cognitive changes.

Discussion

The cognitive improvements associated with exercise are likely driven by increased metabolic activity, cerebrovascular mechanisms, and neuroplasticity throughout the brain. Our paper shows the promise in, and need for, high-quality trials integrating cognitive and brain function measures to elucidate the functional relationship between exercise and brain health in populations with a high risk of dementia.

Systematic review registration

PROSPERO, identifier: CRD42022291843.

Effectiveness of lifestyle medicine on cognitive functions in mild cognitive impairments and dementia: A systematic review on randomized controlled trials

Mild cognitive impairment (MCI) and dementia are associated with lifestyle risk factors, making lifestyle medicine a potentially viable intervention for people with MCI and dementia. The present study aims to examine the effectiveness of lifestyle medicine on cognitive functions among people with MCI and dementia, by performing a systematic review and meta-analysis on randomized controlled trials (RCT). A systematic literature search was conducted to extract RCTs adopting lifestyle interventions of diet, exercise, and stress management or emotional well-being. Results showed that 65 studies were eligible. Exercise was the most promising lifestyle intervention that improved various cognitive functions among people with MCI and dementia, and was more effective in MCI than in dementia. Interventions on stress management or emotional well-being did not show a significant effect on people with MCI, and the evidence for people with dementia was insufficient to conclude. Similarly, due to the lack of RCTs on a healthy dietary pattern, the effectiveness of diet interventions was not examined. In conclusion, the exercise component of lifestyle medicine can be an effective and clinically significant intervention for protecting people with MCI and dementia against cognitive declines, especially when served as an early intervention at the stage of MCI.

Effects of preventive interventions on neuroimaging biomarkers in subjects at-risk to develop Alzheimer's disease: A systematic review

Alzheimer's Disease (AD) is a multifactorial and complex neurodegenerative disorder. Some modifiable risk factors have been associated with an increased risk of appearance of the disease and/or cognitive decline. Preventive clinical trials aiming at reducing one or combined risk factors have been implemented and their potential effects assessed on cognitive trajectories and on AD biomarkers. However, the effect of interventions on surrogate markers, in particular imaging biomarkers, remains poorly understood. We conducted a review of the literature and analyzed 43 interventional studies that included physical exercise, nutrition, cognitive training or multidomain interventions, and assessed various brain imaging biomarkers, to determine the effects of preventive interventions on imaging biomarkers for subjects at-risk to develop AD. Deciphering the global and regional brain effect of each and combined interventions will help to better understand the interplay relationship between multimodal interventions, cognition, surrogate brain markers, and to better design primary and secondary outcomes for future preventive clinical trials. Those studies were pondered using generally-admitted quality criteria to reveal that interventions may affect the brain of patients with cognitive impairment rather than those without cognitive impairment thus indicating that particular care should be taken when selecting individuals for interventions. Additionally, a majority of the studies concurred on the effect of the interventions and particularly onto the frontal brain areas.

Cardiorespiratory Fitness as a Moderator of Sleep-Related Associations with Hippocampal Volume and Cognition

The objective of this study was to understand the associations of sleep and cardiorespiratory fitness with hippocampal volume and global cognition among older adults (n = 30, age = 65.8 years, female = 73.3%). Wrist actigraphy provided objective measures of nighttime sleep including sleep duration, average wake bout length (WBL; sleep disturbance), and wake-to-sleep transition probability (WTSP; sleep consolidation). Cardiorespiratory fitness was quantified via cycle exercise using a modified heart rate recovery approach. Magnetic resonance imaging was used to determine hippocampal volume and the Mini-Mental State Examination was used to assess global cognition. Fitness moderated associations of sleep with hippocampal volume and cognitive performance, whereby the association of WBL-an index of poor sleep-with hippocampal atrophy was stronger among less-fit individuals, and the association of sleep duration with cognitive performance was stronger among more-fit individuals. Across the fitness levels, a longer WBL was associated with lower cognitive performance, and a higher WTSP-an index of more consolidated sleep-was associated with greater hippocampal volume. Sleep and fitness were unrelated to the volume of an amygdala control region, suggesting a degree of neuroanatomical specificity. In conclusion, higher cardiorespiratory fitness may attenuate sleep disturbance-related hippocampal atrophy and magnify the cognitive benefits of good sleep. Prospective studies are needed to confirm these findings.

Neural Synchrony During Naturalistic Information Processing Is Associated With Aerobically Active Lifestyle and Cardiorespiratory Fitness in Cognitively Intact Older Adults

The functional neural mechanisms underlying the cognitive benefits of aerobic exercise have been a subject of ongoing research in recent years. However, while most neuroimaging studies to date which examined functional neural correlates of aerobic exercise have used simple stimuli in highly controlled and artificial experimental conditions, our everyday life experiences require a much more complex and dynamic neurocognitive processing. Therefore, we have used a naturalistic complex information processing fMRI paradigm of story comprehension to investigate the role of an aerobically active lifestyle in the processing of real-life cognitive-demanding situations. By employing the inter-subject correlation (inter-SC) approach, we have identified differences in reliable stimulus-induced neural responses between groups of aerobically active (n = 27) and non-active (n = 22) cognitively intact older adults (age 65–80). Since cardiorespiratory fitness has previously been suggested to play a key role in the neuroprotective potential of aerobic exercise, we have investigated its dose-response relationship with regional inter-subject neural responses. We found that aerobically active lifestyle and cardiorespiratory fitness were associated with more synchronized inter-subject neural responses during story comprehension in higher order cognitive and linguistic brain regions in the prefrontal and temporo-parietal cortices. In addition, while higher regional inter-SC values were associated with higher performance on a post-listening memory task, this was not translated to a significant between-group difference in task performance. We, therefore, suggest that the modulatory potential of aerobic exercise and cardiorespiratory fitness on cognitive processing may extend beyond simple and highly controlled stimuli to situations in which the brain faces continuous real-life complex information. Additional studies incorporating other aspects of real-life situations such as naturalistic visual stimuli, everyday life decision making, and motor responses in these situations are desired to further validate the observed relationship between aerobic exercise, cardiorespiratory fitness, and complex naturalistic information processing.

Exercise Training for Mild Cognitive Impairment Adults Older Than 60: A Systematic Review and Meta-Analysis

Background:

The prevalence of mild cognitive impairment (MCI) continues to increase due to population aging. Exercise has been a supporting health strategy that may elicit beneficial effects on cognitive function and prevent dementia.

Objective:

This study aimed to examine the effects of aerobic, resistance, and multimodal exercise training on cognition in adults aged > 60 years with MCI.

Methods:

We searched the Cochrane Library, PubMed, and Embase databases and ClinicalTrials.gov (https://clinicaltrials.gov) up to November 2021, with no language restrictions. We included all published randomized controlled trials (RCTs) comparing the effect of exercise programs on cognitive function with any other active intervention or no intervention in participants with MCI aged > 60 years.

Results:

Twelve RCTs were included in this review. Meta-analysis results revealed significant improvements in resistance training on measures of executive function (p < 0.05) and attention (p < 0.05); no significant differences were observed between aerobic exercise and controls on any of the cognitive comparisons.

Conclusion:

Exercise training had a small beneficial effect on executive function and attention in older adults with MCI. Larger studies are required to examine the effects of exercise and the possible moderators.

Protocol for SYNchronising Exercises, Remedies in GaIt and Cognition at Home (SYNERGIC@Home): feasibility of a home-based double-blind randomised controlled trial to improve gait and cognition in individuals at risk for dementia

INTRODUCTION

Physical exercise and cognitive training have the potential to enhance cognitive function and mobility in older adults at risk of Alzheimer's disease and related dementia (ADRD), but little is known about the feasibility of delivering multidomain interventions in home settings of older adults at risk of ADRD. This study aims to assess the feasibility of home-based delivery of exercise and cognitive interventions, and to evaluate the relationship between participants' intervention preferences and their subsequent adherence. Secondary objectives include the effect of the interventions on ADRD risk factors, including frailty, mobility, sleep, diet and psychological health.

METHODS AND ANALYSIS

The SYNchronising Exercises, Remedies in GaIt and Cognition at Home (SYNERGIC@Home) feasibility trial is a randomised control trial that follows a 2×2 factorial design, with a 16-week home-based intervention programme (3 sessions per week) of physical exercises and cognitive training. Participants will be randomised in blocks of four to one of the following four arms: (1) combined exercise (aerobic and resistance)+cognitive training (NEUROPEAK); (2) combined exercise+control cognitive training (web searching); (3) control exercise (balance and toning)+cognitive training; and (4) control exercise+control cognitive training. SYNERGIC@Home will be implemented through video conferencing. Baseline and post-intervention assessments at 4-month and 10-month follow-up will include measures of cognition, frailty, mobility, sleep, diet and psychological health. Primary feasibility outcome is adherence to the interventions. Primary analytic outcome is the relationship between pre-allocation preference for a given intervention and subsequent adherence to the allocated intervention. A series of secondary analytic outcomes examining the potential effect of the individual and combined interventions on cognitive, mobility and general well-being will be measured at baseline and follow-up.

ETHICS AND DISSEMINATION

Ethics approval was granted by the relevant research ethics boards. Findings of the study will be presented to stakeholders and published in peer-reviewed journals and at provincial, national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04997681, Pre-results.