SYNchronizing Exercises, Remedies in GaIt and Cognition (SYNERGIC): A Randomized Controlled Double Blind Trial
Phase: NA
Conditions: Mild Cognitive Impairment
Sponsor: London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's

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SYNchronizing, Exercises, Remedies in GaIt and Cognition (SYNERGIC). A 
randomized controlled double blind trial. 
 
 
CCNA-2019 
The Canadian Consortium for Neurodegeneration in Aging 
15-February-2019 
 
HC6-24-c195918 Protocol #201619 
NCT02808676 
 
*Confidentially Statement 
The information contained in this document is privileged and confidential. Any disclosure is prohibited unless such 
disclosure is required by applicable laws and regulations. Persons to whom the information is disclosed must be informed 
that the information is privileged and confidential and it may not be further disclosed by them. 
 
 
 
 
 
 
 
 
 
 
 
 
 

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SYNERGIC TRIAL (SYNchronizing Exercises, Remedies in GaIt and Cognition) 
A Randomized Controlled Double Blind Trial 
Table of Contents 
1. 
INTRODUCTION .......................................................................................................................................6 
1.1 Background...........................................................................................................................................6 
2. 
STUDY DESIGN and HYPOTHESES..............................................................................................................7 
2.1. HYPOTHESES ........................................................................................................................................7 
3. 
DESIGN ...................................................................................................................................................8 
4. STUDY OUTCOMES......................................................................................................................................9 
4.1 Primary Outcome: .................................................................................................................................9 
4.2 Secondary Outcomes .............................................................................................................................9 
5.  STUDY POPULATION................................................................................................................................. 10 
5.1 Participants, recruitment, stratification, and blinding ............................................................................ 10 
5.2 Inclusion and Exclusion criteria............................................................................................................. 10 
Inclusion criteria:.................................................................................................................................. 10 
Exclusion criteria: ................................................................................................................................. 11 
5.3 Sample size: ........................................................................................................................................ 12 
6. STUDY PROCESS ........................................................................................................................................ 12 
6.1 Interventions ...................................................................................................................................... 12 
6.1.1 Cognitive Training (Multimodal CT-intervention) ................................................................................ 13 
6.1.2 Exercises (Multimodal Exercise – Intervention)................................................................................... 14 
6.1.3 Vitamin D supplementation............................................................................................................... 15 
6.2 Control/Placebos................................................................................................................................. 16 
7.0 STUDY PROCEDURES ............................................................................................................................... 17 
7.1 Screening Session (Visit 1).................................................................................................................... 18 
7.2 Baseline Evaluation (Visit 2) ................................................................................................................. 19 
7.2.1 Treatment Allocation ........................................................................................................................ 19 
7.2.2 Blinding............................................................................................................................................ 20 
7.3 Visit 3 – 6 month follow-up visit ........................................................................................................... 20 
7.4 Telephone Follow-Up (9 month post-baseline testing) ........................................................................... 20 
7.5 Visit 4 – 12 month follow-up visit ......................................................................................................... 21 
7.6 Study Procedure Descriptions .............................................................................................................. 21 

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7.6.5 Cognitive Outcomes.......................................................................................................................... 22 
7.6.6 Mobility Outcomes ........................................................................................................................... 25 
7.6.7 Functional Outcomes and Combined Score of Cognition and Functionality (Pooled Index) .................... 27 
7.6.8 Quality Of Life Outcomes .................................................................................................................. 28 
7.6.9 Health Resource Utilization ............................................................................................................... 28 
8. ANALYSIS .................................................................................................................................................. 29 
Analysis, planned analysis, frequency of analysis, and correction for multiple testing ................................ 29 
9. ADVERSE EVENT (AE) AND SERIOUS ADVERSE EVENT REPORTING (SAE) ....................................................... 30 
9.1 Concomitant Medications .................................................................................................................... 30 
9.2 Rescue Medication and Risk Management ............................................................................................ 31 
9.3 Premature Withdrawal/Discontinuation Criteria ................................................................................... 31 
10. ETHICAL CONSIDERATIONS ...................................................................................................................... 31 
10.1 Confidentiality of Participant Records ................................................................................................. 32 
11. ADMINISTRATIVE REQUIREMENTS ........................................................................................................... 32 
11.1 Protocol Amendments ....................................................................................................................... 32 
11.2 Completion of Case Report Forms (CRFs) ............................................................................................ 32 
11.3 Monitoring Procedures ...................................................................................................................... 32 
12. PUBLICATION POLICY .............................................................................................................................. 32 
12.1 Participating Centers ......................................................................................................................... 32 
AppendIX I................................................................................................................................................ 42 
 
 
 
 
 
 
 

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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
Abbreviations 
 
ADAS-Cog 
Alzheimer’s Disease Assessment Scale Cognition Plus 
ADCS 
Alzheimer's Disease Cooperative Study 
ADL 
Activities of Daily Living 
ADNI 
The Alzheimer’s Disease Neuroimaging Initiative 
ANOVA 
Analysis of Variance 
BDNF 
Brain-Derived Neurotrophic Factor 
BNT 
Boston Naming Test 
CCNA 
Consortium in Neurodegeneration and Aging 
CDR 
Clinical Dementia Rating Scale 
cE 
Control Tone-Stretching Exercises 
CERAD 
Consortium to Establish a Registry for Alzheimer’s Disease 
CT 
Cognitive Training 
cCT 
Control Cognitive Training 
DM 
2 Tasks at Once 
E 
Multi-Modal Exercises 
FLAIR 
Fluid Attenuation Inversion Recovery  
fMRI 
Functional MRI 
GAD-7 
Generalized Anxiety Disorder 7-item scale 
GDS-30 
Geriatric Depression Scale 
IADL 
Instrumental Activities of Daily Living 
ICH-GCP 
Harmonization Good Clinical Practice 
IRB 
Institutional Review Board 
IU 
International units 
K-M 
Kaplan-Meier 
LORIS 
Longitudinal Online Research and Imaging System 
MCI 
Mild Cognitive Impairment 
MMSE 
Mini Mental State Examination 
MoCA 
Montreal Cognitive Assessment 
MRI 
Magnetic Resonance Imaging 
PARQ+ 
Physical Activity Readiness Questionnaire Plus 
PASE 
Physical Activity Scale for the Elderly 
PRT 
Progressive resistance training 
PTH 
Parathyroid hormone  
RAVLT 
Rey auditory verbal learning 
RPE 
rate of perceived exertion 
RT 
Reaction time 
SYNERGIC 
SYNchronizing Exercises, and Remedies in GaIt and Cognition 
SDST 
Symbol digit substitution test 
SF-36 
Quality of life questionnaire – short form 
SPPB 
Short physical performance battery 

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TMT 
Trail making test 
VBM 
Voxel-Based Morphometry 
WAIS 
Wechsler Abbreviated Scale of Intelligence 
WMHs 
White Matter Hyper-intensities 
VEGF 
Vascular endothelial growth factor 
6MWT 
Six Minute Walk Test 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1. INTRODUCTION 
1.1 BACKGROUND 
Exercises, specifically resistance and aerobic training, have been demonstrated to improve cognitive 
outcomes, along with improved physical capacity and mobility[1,2]. Both aerobic [3] and resistance 
training[4] trials of different durations have revealed impressive results, with the most consistent 
findings being observed after combined interventions, multimodal exercise- lasting roughly six months 
to one year[1]. For example, our group has recently reported that aerobic exercise improves performance 
on learning a new sequence of movements. Although the training benefits of progressive resistance 
training (PRT) have been well documented, PRT has been studied far less extensively than aerobic 
training in patients with Mild Cognitive Impairment (MCI).  
Exercise training is beneficial for cognition even in frail older adults and in those with low mobility as 
has been shown by our group[4].  Exact mechanisms supporting the benefits of exercises for cognition 
in humans need to be further explored but  numerous studies in animals and humans have demonstrated 
that aerobic exercise may have neuroprotective and neurorestorative effects [4,5,5,6].  The rationale of 
combining aerobic and progressive resistance training as a multimodal exercise intervention is supported 
by research that has revealed potential beneficial effects on insulin-like growth factor-1, insulin 
sensitivity, and anti-inflammatory and brain-derived neurotrophic factor pathways, which are related to 
both sarcopenia and cognitive decline[7]. In addition, multimodal exercise interventions have shown 
positive effects on muscle/lean mass, cognition and brain volume [8]. 
Similarly, cognitive training (e.g. computer based cognitive process training) has also shown positive 
results in improving cognition, mobility and postural control. Several recent systematic reviews on the 
topic[9,10] support the cognitive benefits of training and a seated dual-task cognitive training regimen 
designed by our group has demonstrated that this type of training can also improve balance in healthy 
older adults.[11] In line with exercise training, recent research on cognitive training has also supported 
important improvements in brain plasticity post-intervention [12,13].  
In addition, vitamin D deficiency has been linked to cognitive dysfunction, dementia and mobility 
decline. [1,14-16] Besides its very well-known effects on muscle and bone physiology, vitamin D is 
considered a neurosteroid hormone which exhibits neuroprotective attributes through antioxidative 
mechanisms, 
neuronal 
calcium 
regulation, 
immunomodulation, 
enhanced 
nerve 
conduction 
and 
detoxification mechanisms.[14,17-20] Compelling evidence from animal models and epidemiological 
studies supports a potential beneficial role for vitamin D on cognitive function. In this trial, we will test 

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if vitamin D supplementation will have a synergistic effect in improving or stabilizing cognitive function 
in combination with exercises and cognitive training. 
Mild Cognitive Impairment is thought to be the optimum stage to intervene with preventive strategies 
and early treatments, in fact it is estimated that one-year delay in dementia incidence could save $109 
billion over a 30 years period the Canadian Health System.[21,22] Robustly designed trials, with 
longitudinal follow-up, have been recommended in MCI to investigate the comparative benefits of 
isolated and combined physical exercises and cognitive training. To date, the effect of adding cognitive 
training and vitamin D to multimodal physical exercises for improving global cognition, executive 
function and memory in  MCI has not been assessed.[23]  
The proposed SYNERGIC TRIAL (SYNchronizing Exercises, and Remedies in GaIt and Cognition) 
is uniquely designed to evaluate the effect of aerobic and progressive resistance training exercises, 
isolated or combined with cognitive training and vitamin D supplementation, in older adults with MCI. 
This trial will be conducted by the Motor Exercise and Cognition Team which is part of the Canadian 
Consortium in Neurodegeneration and Aging (CCNA) and the Canadian Gait and Cognition Network 
(CGCN). 
 
2. STUDY DESIGN AND HYPOTHESES 
 
2.1. HYPOTHESES  
 
2.1.a Primary Hypotheses  
1. Twenty weeks (five months) of supervised multimodal exercise (aerobic and progressive 
resistance training) alone and/or in combination with cognitive training (CT) and/or oral 
vitamin D will significantly improve global cognitive function in older adults with MCI, as 
assessed by primary outcome Alzheimer’s Disease Assessment Scale-Cognitive subscale 
plus (ADAS-Cog Plus). 
2. Multimodal exercise alone and/or in combination with CT and/or oral vitamin D would 
significantly improve secondary cognitive outcomes across memory, executive function, and 
attention, as well mobility outcomes related to falls risk and dual-task gait, and dual-task gait 
cost.  

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3.  The combination of CT and oral vitamin D with multimodal exercise will be significantly 
superior to either intervention alone for cognitive and functional benefits, demonstrating a 
synergistic effect. 
4. Mechanistically, our intervention will significantly improve hippocampi volume, blood 
biomarkers, and BDNF levels [24], and fMRI prefrontal activation in executive control dual-
task condition.  
 
2.1.b Secondary Hypotheses 
1. All active training interventions will improve brain morphology and biochemistry compared with 
control –placebo-interventions as defined by: increased hippocampal volume (mm3) by MRI 
scanning; positive localized Voxel-Based Morphometry (VBM) brain changes (z-score relative 
change); decreased whole brain volume of White Matter Hyper-intensities (WMHs) (mm3); and 
lead to beneficial hippocampal and anterior and posterior cingulate MRS metabolite changes (% 
increase in N-acetylaspartate, and increase in phosphocreatine metabolites). 
2. All active interventions will improve secondary cognitive outcomes, in the domains of attention, 
memory, fluency, and executive function, relative to the control condition, and combined 
training will be superior to either single intervention. 
3. Multimodal exercise will preferentially decrease inflammatory markers, and increase fitness 
(strength and aerobic capacity), muscle strength, and functional mobility, compared to either 
cognitive or control condition. 
4. Cognitive and physical training will produce positive effects on psychological health and quality 
of life (SF-36) above and beyond the non-specific effects seen after control condition. 
3.  DESIGN 
The SYNERGIC TRIAL (SYNchronizing Exercises, and Remedies in GaIt and Cognition) is a 
Randomized, modified factorial design with parallel-groups (five arms), and double-blind study 
evaluating the cognitive effect of multimodal exercises (as a main intervention) combined with and 
without cognitive training and vitamin D. This is achieved using 4 arms (1 to 4) and a 5th arm is added 
as a control group. Figure 1 illustrates the trial design and Figure 2 summarizes the timeline of the trial 
consisting of an approximate 12-18 months enrolment period, and 12 months of follow-up.  The trial 
adheres to the Consolidated Standards of Reporting Trials (CONSORT) guidelines for conducting and 
reporting clinical trials, as extended to non-pharmacologic interventions. Two hundred (200) 

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participants with Mild Cognitive Impairment (MCI), aged 60 and older will be enrolled and randomized 
into one of five arms.  
Arm 1: multimodal exercises + cognitive training + Vitamin D 
Arm 2: multimodal exercises + cognitive training + placebo D  
Arm 3: multimodal exercises+ control cognitive training + Vitamin D 
Arm 4: multimodal exercises + control cognitive training+ placebo D;  
Arm 5: tone-stretching exercises + control cognitive training+ placebo D. 
 
Note: in bold are the active interventions. Arm 5 is the arm with pure control interventions.  
Figure 1 shows the flow chart of the trial. E: multimodal exercises; CT: cognitive training; cE: control 
tone-stretching exercises; and cCT: control cognitive training. 
4. STUDY OUTCOMES 
4.1 PRIMARY OUTCOME: Global cognition assessed using the ADAS-Cog Plus.[25]  
We expect that our combined interventions, over 20 weeks, will show improvement and/or less decline 
in global cognition. We expect a three (3) point change (continuous variable) across full intervention/ 
control groups on the ADAS-Cog Plus scores, a value we considered clinically significant based in 
previous studies using the ADAS-Cog 13 items. This expected change/ improvement is similar in 
magnitude to the improvements seen in positive pharmacological clinical trials in dementia in the 
ADAS-Cog .[26] Additionally, improving in the proportion of participants, expressed as percentages per 
allocated groups, with abnormal ADAS-Cog Plus (dichotomous variable) after intervention will be 
considered success of the intervention. ADAS-Cog Plus is described in detail in Section 7. We also 
expect a significant statistical improvement in the overall transformed score of ADAS-Cog Plus 
calculated using a validated scoring system[27]  Observing a statistically significant difference in this 
primary outcome will be considered preliminary evidence of efficacy. 
4.2 SECONDARY OUTCOMES 
Secondary outcomes include neuroimaging, cognitive (neuropsychological assessments), gait and 
mobility outcomes including incidence of fall, blood biomarkers, quality of life scorings, as described in 
our primary and secondary hypotheses. Secondary outcomes are described in detail in Section 7. 

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5.  STUDY POPULATION 
5.1 PARTICIPANTS, RECRUITMENT, STRATIFICATION, AND BLINDING 
We will target older adults aged 60 and over with MCI. Interventions will be done across five sites: 
London (lead and sponsor site, target recruitment: 70 participants), Waterloo-University of Waterloo 
(target recruitment: 25), Waterloo-Wilfrid Laurier University (target recruitment: 20), Montreal (target 
recruitment: 30) and Vancouver (target recruitment: 55). Each intervention site may have more than one 
recruitment center. For those who are interested in participating, a consent and screening session will be 
arranged as described in our participant flowchart, Figure 3. 
Once informed consent is obtained, we will perform the screening tests. Those who remain eligible after 
the screening session including the Physical Activity Readiness Questionnaire Plus (PARQ+) and who 
provide written recommendation from their physician or site physician indicating their appropriateness 
to participate in an aerobic-based exercise training program will proceed to baseline assessments. 
Participants will be informed that they will be randomly assigned to one of five arms by the research 
coordinator and will be blinded to the investigators' hypothesis as to which is the preferred intervention 
arm.  
All groups will have an equal volume and frequency of contact with trainers over the 12 months of the 
study. All primary and secondary outcomes will be obtained and analyzed by blinded assessors on 
different days to the training programs. 
5.2 INCLUSION AND EXCLUSION CRITERIA 
Inclusion criteria:  
Participants must meet each of the following criteria for enrolment into the study: 
1. At least 60 years of age. 
2. Self-reported levels of proficiency in English or French (at Montreal site only) for speaking 
and understanding spoken language. 
3. Able to comply with scheduled visits, treatment plan, and other trial procedures. 
4. Able to ambulate at least 10 m independently. 
5. Having MCI defined following Albert et al.[28] criteria as: 
a-Objective cognitive impairment in one of the following four cognitive domains: memory, 
executive function, attention, and language operationalized using one or more of the 
following: MoCA Test (Montreal Cognitive Assessment) with scores ranging from 13-24/30, 
Logical Memory below ADNI cutoffs, CERAD word list recall < 6. 

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b-Preserved activities of daily living operationalized as a Score >14/23 on the Lawton-Brody 
IADL[29] scale and confirmed by clinician’s interviews. 
c-Absence of dementia using criteria from the Diagnostic and Statistical Manual of Mental 
Disorders, Fifth Edition [30] and/or Global CDR = 0.5. 
6. Having normal or corrected to normal vision in at least one eye so that they can identify 
symbols and stimuli presented on a computer screen in front of them.  
7. Must be in sufficient health to participate in the study’s aerobic-based exercise training 
program. This will be determined using the PARQ+ screening tool and with an evaluation by 
a certified exercise physiologist and/or a physician, when appropriate indicating clearance to 
participate in an aerobic-based exercise training program. 
Exclusion criteria: 
Participants who exhibit any of the following conditions are to be excluded from the study: 
1. Serious underlying disease which, in the opinion of the investigator, may preclude 
engagement in interventions or may interfere with the participant’s ability to participate fully 
in the study. 
2. Participant with uncontrolled major depression, schizophrenia, severe anxiety and drug 
abuse.  
3. Current parkinsonism or any neurological disorder with residual motor deficits (e.g. stroke 
with motor deficit), active musculoskeletal disorders (e.g. severe osteoarthritis of lower 
limbs) or history of knee/hip replacement affecting gait performance at clinical evaluation 
4. Intention to enroll in other clinical trials during the same time period. 
5. Pre-existing or current active participation in physical activity program involving aerobic or 
resistance training regimen in previous 6 months. 
6. Taking Cognitive enhancers, Neuroleptics, Anticholinergics, or Vitamin D in doses more 
than 1000IU/day or equivalent. 
7. Known hypercalcemia and/or disorder that is cause of hypercalcemia (e.g. 
hyperparathyroidism/ Paget’s disease/ Sarcoidosis). 
8. Known renal/kidney insufficiency. 
9. Uncontrolled hypertension. 
10. Uncontrolled diabetes. 

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5.3 SAMPLE SIZE: 
Sample size calculation is based on changes in our main primary outcome:  stabilization/improvement in 
cognition as measured using the Alzheimer Disease Assessment Scale Cognitive Plus (ADAS-Cog 
Plus). We expect a change of three (3) points on the ADAS-Cog Plus scores, a value that is considered 
clinically 
significant, 
and 
it 
is 
similar 
in 
magnitude 
to the improvements seen in positive 
pharmacological clinical trials in dementia.[26]  Two previous studies testing the effect of exercises on 
cognition in 200 MCI participants shown a mean score of 6-7 and a standard deviation of 3 in the 
ADAS-Cog.[24,31] Based on these data and assuming a mean change of 3 points in the ADAS-Cog, 34 
participants per arm are required to have 80% power to detect a change of three points or more on the 
ADAS-Cog with a 2-tailed α error of 5%, adjusted for 10 potential pairwise comparisons.  We estimate a 
worst case scenario of 15% of dropout rate during the 20 weeks of follow up to the main endpoint. 
Therefore, we will aim to recruit 40 per arm for a total of 200 participants.  
 Sample size estimates per group for the primary outcome: change in ADAS-Cog Plus  
 
Type I error=0.05 
Type I error=0.01 
Type I error=0.001 
Power=80%  
34 
50 
59 
Power=90%  
51 
54 
70 
Power=99%  
68 
82 
102 
 
Reference: Independent Groups - Machin D, Campbell M, Fayers, P, Pinol A (1997) Sample Size Tables for Clinical Studies 
 Second Ed. Blackwell Science IBSN 0-86542-870-0 p. 24-25 
6. STUDY PROCESS 
6.1 INTERVENTIONS 
All participants will complete three (3) group training sessions per week (total 20 weeks), under the 
supervision of trainers. Each session will last approximately 90 minutes and will be comprised of 30 
minutes cognitive training (CT) or control cognitive training (cCT) followed by approximately 60 
minutes of combined aerobic and progressive strengthening exercise (E) or control tone-stretching 
exercise (cE) and. All participants will receive a vitamin D (tablet 10,000 IU) or placebo three times per 
week. 
Within each small group of up to eight individuals, participants follow the program tailored to their 
individual functioning level, with constant monitoring by the trainers.  Participants are expected to 
attend all training sessions and research staff will strongly encourage them to do so.  Each training group 
will have 1-2 trainers present each session to ensure a ratio of one (1) trainer per four (4) participants. To 

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avoid potential imbalances in exposure time, control interventions for exercise and cognitive training 
will have the same duration. 
Throughout the 12 month trial, participants will be provided with falls calendars, in which they will 
record any falls that have occurred, and they will be asked to bring them at the training sessions. At the 
completion of the 20-week intervention, participants are not given ongoing access to the training. During 
follow-up, participants will be called three months after their completion of the intervention to track 
incidence of falls, adverse outcomes, such as emergency room visits and change of medications; 
physical activity will be also be tracked  using the Physical Activity Scale for the Elderly (PASE). 
Following assessments at 6 and 12 months, participants will receive a compensation of $50 for their 
participation for a total of $100. 
6.1.1 COGNITIVE TRAINING (MULTIMODAL CT-INTERVENTION) 
Cognitive Training (CT) intervention will involve tablet-based multimodal and multi-domain dual-task 
training with memory load. The training uses the custom-written program, developed for neuro-
rehabilitation and used in previous research trials for cognitive [32-34] and mobility outcomes [11]. 
Training sessions will take place in groups of up to eight participants before each of the fitness-training 
session for duration of 30 min max. Participants will perform a concurrent visuo-motor task (dual-task 
combination) composed of different sets of visual stimuli that have to be identified by tapping 
designated figures on an iPad (or an Android tablet).  Participants will perform discrimination tasks 
involving sets of items (e.g. letters, numbers, animals, vehicles, fruits, celestial bodies). Each session 
will involve two sets of items, one for each task. The combination of sets of items will change every 
four sessions.  
Task instructions will always be administered by a trained Research Assistant. Within each training 
session and for each task combination, participants will complete a first block of single-pure (SP) trials 
followed by mixed-trial blocks with single-task trials (SM) intermixed and dual-mixed trials (DM: 2 
tasks at once). Each training session will involve 80 SP, 128 SM and 192 DM trials (thus 40% of the 
DM blocks will be SM trials). Within the DM trials, the first 30 training sessions will be performed 
following a fixed priority instruction (participants will be asked to keep an equal priority on left and 
right hands.) The following 30 sessions will be performed following a variable priority instruction 
(participants will be told to vary priority from one hand to another in different blocks). Participants will 
complete a total of 60 sessions. Importantly, an adaptive continuous feedback on performance was will 
be provided during the dual-mixed block of the training sessions.  

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Feedback will take the shape of a speedometer whose indicator moves and changes colour (green, 
yellow, orange or red) to inform participants of their response speed. Two speedometers (one for each 
hand) will be displayed at the top of the screen. Each speedometer is associated to one task. In equal 
priority blocks, participants will be asked to try to maintain both speedometers at least in the yellow 
zone and prevent them from turning to red.  In variable priority blocks, participants will be asked to 
maintain the speedometer associated to the prioritized task in the green zone, while the other 
speedometer can be at least in the orange zone.  The colour of the speedometers will be determined by 
the average reaction time (RT) on the last three trials’ RT for the DM block compared to the median RT 
for the SM trials multiplied by a factor of 1.5 (for the first training session, as there are no previous SM 
trials, the DM block will be compared to 1500ms). In addition, a feedback will be provided at the end of 
the session, where participants will be informed of mean RT and accuracy achieved throughout sessions 
(presented in a histogram without explicit values).  
 
6.1.2 EXERCISES (MULTIMODAL EXERCISE – INTERVENTION) 
The exercises training program involves 3 weekly sessions of approximately 60 min each. All sessions 
will be held in appropriate gym facilities and take place between Monday and Friday ensuring that there 
are not three consecutive days (i.e. training can occur on Monday, Wednesday and Friday or Monday, 
Thursday and Friday etc.). Staff with experience and/or certification in exercises (graduate student in 
kinesiology, Canadian Society of Exercise Physiology certificates, etc.) will supervise all training 
sessions with at least one coach per four participants.  
After a general warm-up, participants will execute the strength-training portion by performing light 
strengthening exercises (pushes and pulls using elastic bands, chair stands, and forward lunges). The 
next phase will include the following exercises: leg press, leg flexion (lower body), seated press, seated 
row, and seated pull (upper body). These exercises are made in a circuit alternating between lower and 
upper body exercises.  A list of suggested exercises base on muscle groups will be provided to the 
trainers (see appendix II).  The recovery period between exercises corresponds to the time needed to 
move from one station to another.  While the first portion of this training protocol (12 weeks) will be 
dedicated to strength endurance exercises the following 12 weeks will focus on maximal strength.  
Training volume and intensity are described in the table below.  Sets represent the number of circuit 
rounds while repetitions are maximal, which means that the resistance must be adjusted by the trainer so 
that the participant reaches exhaustion at the last prescribed repetition of each set.  Training prescription 
for all exercises is made in accordance to the American College of Sport Medicine (ACSM) guidelines 
for strength development in older adults (ACSM, version 1998).  

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Weeks 
Sets 
Repetitions 
Rest between sets 
(sec) 
Day 
1 
Day 
2 
Day 
3 
Day 1 
Day 2 
Day 3 
1-4 
2 
2 
2 
15-18 
15-18 
15-18 
30 
5-8 
3 
2 
3 
12-15 
12-15 
12-15 
30 
9-12 
3 
2 
3 
10 
10 
10 
60 
13-16 
2 
3 
2 
8 
12 
8 
60 
17-20 
3 
2 
3 
6 
8 
6 
60 
 
Following the strength portion of each session, an aerobic training will be prescribed.  Participants will 
be asked to complete 10-20 minutes of cardiovascular exercises using different ergometers (treadmill, 
elliptical machines, cycling ergometers, rowing machines etc.), using steps or other forms of free aerobic 
exercises, as long as the cognitive load is minimized.  Intensity will be monitored using a Borg scale (0-
10) and the target will correspond to 5-6 for the first month, 6-7 for the second month and 7-8 for the 
last month.  Details of the aerobic training are presented in the table below.  Each session will end with a 
five (5) minute recovery period, which will consist of different breathing exercises and stretching. 
 
Weeks 
Sets 
Duration (min) 
Intensity         
(Borg 0-10) 
Rest between sets 
(minutes) 
1-4 
2 
10 
5-6 
1 
5-8 
2 
10 
5-6 
1 
9-12 
2 
10 
6-7 
1 
13-16 
2 
10 
6-7 
1 
17-20 
2 
10 
7-8 
1 
  
Overall rate of perceived exertion (RPE) will be monitored using a Borg scale (0-10) 30 minutes after 
the end of each session.  Participants will have to rate the overall difficulty of the training session. These 
results will provide information about the training load (session RPE – sRPE), monotony and strain. 
6.1.3 VITAMIN D SUPPLEMENTATION  
Participants will receive Vitamin D supplementation (1 tablet of 10,000IU of Vitamin D3) or matching 
placebo three times per week in order to reach a weekly cumulative dose of 30,000 IU per week 
(equivalent of 4,258 IU daily). The vitamin D capsules will be provided by the Research Coordinator 

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(RC) in vials at baseline assessment and every four weeks to complete 5 vials during the training period. 
Vials will be returned by the participants to the RC at the end of each 4 weeks block. Rationale and bio-
safety of the dose: The dose of 10,000 IU/day is currently approved by Health Canada as a 
supplementation for elderly patients. Heaney et al. have administered doses of 30,000 IU/day Vitamin 
D3
 to adult men for five months, with no significant changes in serum calcium concentrations or adverse 
reactions.[35-37] A comprehensive review of toxic effects of vitamin D found that the lowest level at 
which an adverse effect was observed was a serum calcidiol concentration of 200 nmol/l, corresponding 
to a daily intake of 40,000 IU. Therefore, three weekly doses of 10,000IU have a 9-fold weekly margin 
of safety of the established safe dose.   
 
6.2 CONTROL/PLACEBOS 
6.2.1 Control Cognitive Training  
The active control cognitive training group will participate in skills training courses based on a 
published study from our research group[38]. Each session will consist of Internet search for 3 hotels, 3 
touristic places and 3 restaurants, of participant’s preference, in cities determined by the instructor at the 
beginning of each training session (a list of cities is presented in the manual of procedures for cognitive 
training). Another task will be watching a 20 minutes National Geographic documentary movie selected 
by the instructor at the beginning of each session; at the end of the movie participants need to answer 
three questions about the watched movie. These iPad tasks will be alternated between sessions to 
prevent boredom. The approximate time to perform both tasks is 20 minutes which is the approximate 
time to complete the dual-task training on the iPad.  
Active control sessions will be held in groups of up to 8 participants and will take place in the same 
context and physical environment used for dual-task training sessions and lead by the same instructors. 
Studies compared dual-task training to single-task training, as a control condition, in order to control for 
exposure of the same specific tasks performed separately [38]. However, it can be argued that single-
task training is not engaging or stimulating enough and does not provide a feeling of progression. In 
response to this, Walton et al. [39] recommended that cognitive training studies use preferably sham 
trainings whereby clinician interaction and participant expectation effects can be reliably matched. 
Therefore, this study will compare dual-task training to a non-specific intervention, more comparable to 
cognitively stimulating activities that older adults can naturally engage in. To assure same time exposure 
and same social interaction than in active intervention, the control intervention will be held in groups 
using the same type of device that is used for the active intervention. 

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6.2.2 Placebo Vitamin D supplementation  
Participants will receive Vitamin D supplementation (1 tablet of 10,000IU of Vitamin D3) or matching 
placebo three times per week in order to reach a weekly cumulative dose of 30,000 IU per week 
(equivalent of 4,258 IU daily). The vitamin D capsules will be provided by the Research Coordinator 
(RC) in vials at baseline assessment and every four weeks to complete 5 vials during the training period. 
Vials will be returned by the participants to the RC at the end of each 4 weeks block. Rationale and bio-
safety of the dose: The dose of 10,000 IU/day is currently approved by Health Canada as a 
supplementation for elderly patients. Heaney et al. have administered doses of 30,000 IU/day Vitamin 
D3
 to adult men for five months, with no significant changes in serum calcium concentrations or adverse 
reactions.[35-37] A comprehensive review of toxic effects of vitamin D found that the lowest level at 
which an adverse effect was observed was a serum calcidiol concentration of 200 nmol/l, corresponding 
to a daily intake of 40,000 IU. Therefore, three weekly doses of 10,000IU have a 9-fold weekly margin 
of safety of the established safe dose.   
6.2.3 Control Exercises (Tone-Stretching Exercises) 
Participants assigned in the control exercise condition will take part in tone-stretching sessions in groups 
of up to 8 participants, supervised by a trainer. The exercises will be devoted to improve muscle tone, 
flexibility, without improving, strength, cardiorespiratory capacity (and mobility). Resistant load and 
number of repetitions will not progress across exercise sessions. The session will start with a 5-minute 
warm-up on the machine of their choice. This will be followed by 50 minutes of stretching exercises that 
will target the entire body, one joint at a time, from head to toes. Exercises will be performed in a seated 
position as much as possible. The stretching program will be based on the one developed by Stanziano et 
al.[39]  The session will end with 5 minutes of relaxation. Variability in exercises performed between 
sessions will be encouraged in order to avoid progression throughout the entire program. 
6.3 Supervision 
All physical exercise training will be fully supervised by research assistants trained in exercise 
physiology or with kinesiology or physical therapy backgrounds or training. Training frequency is 3 
days/week. Each session will take 90 minutes on average.  
7.0 STUDY PROCEDURES 
Baseline measurements will be obtained prior to randomization. There will be three measurement 
sessions: baseline, 6 months, and 12 months (Figure 1, Appendix I). Outcomes will be assessed by 

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trained assessors blinded to group allocation. As outlined in point 5, there are five main 
interventional/assessment centers. Recruitment will be occurring primary in clinics serving MCI 
populations already identifies in each site and from the community. In addition, older persons belonging 
to the community will be invited to participate through different recruitment methods, including case 
findings by phone interviews and recruitments in primary care and geriatrics clinics. Strategies to 
increase the awareness of the study will be implemented through explanatory brochures and a dedicated 
webpage: “www.synergictrial.com”. Results of the mobility tests and laboratory examinations can be 
provided to the participant and to her/his family physician upon their request. Transportation will be 
paid when necessary. Finally, dissemination of our findings will be conducted in the community through 
open discussion sessions and booklets and publications in the local newsletter. 
7.1 SCREENING SESSION (VISIT 1) 
The following study procedures will be performed:  
1. Written informed consent from study participant  
2. Demographic Information  
3. Physical Activity Scale for the Elderly Questionnaire (PASE)  
4. he Mini Mental State Examination (MMSE)  
5. The Montreal Cognitive Assessment (MoCA), Logical Memory 1 & 2, Consortium to Establish a 
Registry for Alzheimer’s Disease (CERAD) Word List Recall 
6. Geriatric Depression Scale (GDS-30) 
7. Generalized Anxiety Disorder 7 (GAD-7) 
8. Clinical Dementia Rating Scale (CDR) 
9. Alzheimer's Disease Cooperative Study Activities of Daily Living (ADCS-ADL) and Lawton 
Brody Instrumental Activities Of Daily Living (IADL) Scale 
10. Physical Activity Readiness Questionnaire Plus (PAR-Q+) 
11. Physical Activity Tracker allocated to study participant 
During the screening session, global cognitive function will be assessed using the MMSE and the 
MoCA[40,41] and Physical Activity Readiness Questionnaire Plus (PAR-Q+) will be also done. 
Physical activity trackers (ActiGraph) will be provided to each participant during the screening session. 
The physical activity tracker will be worn by participants until first baseline assessment visit, which is 
scheduled up to four weeks after screening. This strategy will assure an accurate record of physical 
activity for each participant prior to participating in the training protocol and will be correlated with the 
response on the PASE questionnaires. 

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Height, weight, seated and standing blood pressure, resting heart rate will be measured at screening 
session. Participants will undergo a clinical assessment with baseline to confirm current health status 
and eligibility for study using the PARQ+.  
The participant will be asked to bring an informant with them to complete the CDR. If the participant 
does not have an informant to attend the visit with them, the informant portion of the assessment can be 
completed with the informant by phone the day of the visit. This will be arranged and completed by a 
trained Research Assistant or Coordinator. 
7.2 BASELINE EVALUATION (VISIT 2) 
Participants will undergo rigorous baseline evaluations, which will take place up to four weeks after the 
screening session. Baseline assessments will include neuroimaging, neuropsychological, and gait 
measures. These will be repeated at the 6-month and 12-month follow-up.  
 
1. Log return of the Physical Activity Device  
2. Blood Draw  
3. Clinical Medical Questionnaire 
4. Quality of Life Questionnaire (SF-36) 
5. ADAS-Cog Plus Tests (ADAS-Cog 13 Tests, plus the Digit Span Forward and Backward WAIS-
III, TMT A and B, Digit Symbol Test, Boston Naming Test) 
6. D-KEFS Colour Word Interference Test 
7. Short Physical Performance Battery (SPPB) 
8. Six Minute Walk Test (6MWT) 
9. Dual task control assessment while seated (mental task)  
10. Gait assessment using Gait Mat and Accelerometers (when available) 
11. Schedule Neuroimaging 
7.2.1 TREATMENT ALLOCATION 
Randomization Once informed consent has been obtained and the baseline assessment has been 
completed, participants will be allocated to each of the 5 arms. The randomization sequence of the 
participants will be generated in each site with a minimum of 4 participants recruited using a central, 
web-based randomization service.  The Research Pharmacy will assign the ‘vitamin D/placebo kits’ in 
compliance with randomization lists generated by a computer program and allocation to groups will be 
done with sequentially numbered opaque sealed envelopes. A block randomization by 5 will be applied 
to ensure an appropriate balance of the characteristics of participants between each arm. Permuted 

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blocks of varying size will be employed to ensure balance over time. After baseline assessment, research 
personnel not involved in measurement or intervention will access the web-based randomization service 
to determine the group allocation.  
7.2.2 BLINDING 
In order to minimize a source of bias, this trial is planned to be a double-blinded study. Research 
personnel performing the outcome assessments will be blinded to group allocation. Participants will be 
blinded of intervention.  
7.3 VISIT 3 – 6 MONTH FOLLOW-UP VISIT 
1. Blood Draw 
2. Clinical Medical Questionnaire 
3. Physical Activity Scale for the Elderly Questionnaire (PASE)  
4. Montreal Cognitive Assessment (MoCA) 
5. Geriatric Depression Scale (GDS-30) 
6. Generalized Anxiety Disorder 7 (GAD-7) 
7. Clinical Dementia Rating Scale (CDR) 
8. Alzheimer's Disease Cooperative Study Activities of Daily Living (ADCS-ADL)  
9. Physical Activity Readiness Questionnaire Plus (PAR-Q+) 
10. Quality of Life Questionnaire (SF-36) 
11. ADAS-Cog Plus Tests (ADAS-Cog 13 Tests, plus the Digit Span Forward and Backward WAIS-
III, TMT A and B, Digit Symbol Test, Boston Naming Test) 
12. D-KEFS Colour Word Interference Test 
13. Short Physical Performance Battery (SPPB) 
14. Six Minute Walk Test (6MWT) 
15. Dual task control assessment while seated (mental task)  
16. Gait assessment using Gait Mat and Accelerometers (when available) 
17. Schedule Neuroimaging 
7.4 TELEPHONE FOLLOW-UP (9 MONTH POST-BASELINE TESTING) 
Three months after the end of the intervention, a telephone follow-up will take place to document any 
falls that have been recorded on the participants’ falls calendar. This will be done by the study Site 
Coordinator or Research Assistant. 

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7.5 VISIT 4 – 12 MONTH FOLLOW-UP VISIT 
1. Blood Draw 
2. Clinical Medical Questionnaire 
3. Physical Activity Scale for the Elderly Questionnaire (PASE)  
4. Montreal Cognitive Assessment (MoCA) 
5. Geriatric Depression Scale (GDS-30) 
6. Generalized Anxiety Disorder 7 (GAD-7) 
7. Clinical Dementia Rating Scale (CDR) 
8. Alzheimer's Disease Cooperative Study Activities of Daily Living (ADCS-ADL)  
9. Physical Activity Readiness Questionnaire Plus (PAR-Q+) 
10. Quality of Life Questionnaire (SF-36) 
11. ADAS-Cog Plus Tests (ADAS-Cog 13 Tests, plus the Digit Span Forward and Backward WAIS-
III, TMT A and B, Digit Symbol Test, Boston Naming Test) 
12. D-KEFS Colour Word Interference Test 
13. Short Physical Performance Battery (SPPB) 
14. Six Minute Walk Test (6MWT) 
15. Dual task control assessment while seated (mental task)  
16. Gait assessment using Gait Mat and Accelerometers (when available) 
 
7.6 STUDY PROCEDURE DESCRIPTIONS 
 
7.6.1 Clinical-Medical Questionnaires  
The presence of chronic diseases, comorbidities, chronic medications, history of previous falls will be 
recorded.  Whenever possible, a family member will be also interviewed in order to confirm the medical 
history and functional status. Finally, fear of falling will be assessed using the Falls Efficacy Scale and 
the fear of falling scale. 
7.6.2 Functionality score 
Self-reported information will be collected at baseline, six and twelve month’s assessment on activities 
of daily living (ADLs) than are related to cognitive and physical capabilities. Specifically, the 
Alzheimer's Disease Cooperative Study Activities of Daily Living (ADCS-ADL) Inventory and IADL 
and Lawton Brody Instrumental Activities Of Daily Living (IADL) Scale will be used. 

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7.6.3 Blood Biomarkers 
The following biomarkers will be drawn at the Baseline Visit,Visit 3 and Visit 4: 
 Vitamin D levels, Calcium, PTH, and lipid level will be measured by conventional methods.  
 
Serum High Sensitive CRP, IL-6 , BDNF, and VEGF receptor 1, IGF-1  will be determined by 
standardized  ELISA methods  
Blood samples for this study (completed at baseline and 6-month visit) will be done by a certified study 
Research Coordinator or Research Assistant. Participants will be asked to fast and will be provided with 
a small breakfast after the draw is complete. Samples will be collected, processed and stored securely at 
the respective site in a -80C freezer used for research purposes. Samples will be batch shipped securely 
to a centralized laboratory for analysis. Sample tubes will be labeled appropriately by the Study 
Coordinator with only the participant’s unique study identifier and time point of collection.   
7.6.4 Imaging  
The imaging protocol will follow the Canadian Dementia Imaging Protocol developed for CCNA by 
Dr. Simon Duchesne, Laval University and colleagues, the latter having already been used by members 
of the Consortium pour l’identification précoce de la maladie d’Alzheimer- Québec (CIMA-Q) Pre-post 
regional patterns of brain plasticity will be assessed using structural (high-resolution 3D T1-weighted 
images = 7 min) in order to get voxel-based volumetric and cortical thickness measures, as well as 
diffusion tensor imaging (DTI, 30 directions, with AP/PA correction scan = 7 min) to calculate 
fractional anisotropy and diffusivity in white matter tracts as well as  derive tract-based statistics.  
Cerebrovascular integrity and pathology will be assessed using the following contrasts: PD/T2 = 5 min; 
FLAIR = 7 min, and T2* = 5min).  Functional magnetic resonance imaging at rest (rsfMRI plus field 
map = 12 min) will also be acquired to measure change in data-driven functional networks. Metabolite 
levels will be measured from the right motor cortex, cingulate cortex, and hippocampus, using single 
voxel spectroscopy.  The total time for the scan session including scanning and patient setup is normally 
less than 1.5 hours. 
7.6.5 COGNITIVE OUTCOMES 
 
Alzheimer Disease Assessment Scale- Plus (ADAS-Cog Plus)  
Global cognition will be assessed using the cognitive section of the Alzheimer Disease Assessment 
Scale Plus (ADAS-Cog Plus)[25]. The scale consists of 10 brief cognitive tests assessing memory, 
language, executive function and praxis. Scores range from 0 to 90, with higher scores indicating higher 
severity of cognitive impairment. The ADAS-Cog has been a significant outcome measure in numerous 

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trials with MCI and AD. The ADAS-Cog Plus has marked advantages as an outcome measure in MCI 
populations since incorporates items concerning executive function and functionality. Reliability and 
validity has been confirmed. Since several items are harmonized with the classical ADAS-Cog, it will 
also provide comparability with previous or existing trials assessing intervention in MCI. The ADAS-
Cog Plus includes additional testing in executive function and caregiver reported functionality. 
Executive function of the ADAS-Cog plus is composed by the following tests: Trail-Making Test 
(TMT) A & B, the WAIS-R Digit Symbol Substitution Test (DSST), Digit Span Test, and Category 
Fluency.  
In brief, The TMT (A & B) assesses attention, speed, and mental flexibility. For this test, participants 
connect numbers (TMT-A) and numbers and letters (TMT-B) in order. Time to complete is the outcome 
of interest for this measure. Trails A is truncated at 3 min and Trails B at 5 min. The DSST measures 
speed and information processing. Participants are instructed to refer to a number-symbol key at the top 
of the page and to write the appropriate symbols under the corresponding numbers as quickly as 
possible. For the Digit Span Test, an auditory attention task, participants are asked to recall a series of 
numbers forward and backward. For Category Fluency, a measure of speed and flexibility of verbal 
thought, participants are asked to name as many items as possible in a specified category (vegetables); 
unique responses during the first minute were counted. Functionality will be assessed by the following 
five functionality questions : 1) “Ability of writing checks, paying bills, balancing checkbook;” 2) 
“Assembling tax records, business affairs, or papers”; 3) “Playing a game of skill, working on a hobby;” 
4) “Keeping track of current events;” and 5) “Remembering appointments, family occasions, holidays, 
medications.” 
Trail Making Test (TMT) A & B (s) 
The Trail Making Test (TMT) measures set shifting abilities. Both parts of the test consist of 25 circles 
distributed across a sheet of paper.  For the first portion of the test (TMT A), the participant is required 
to draw lines to connect numbers in ascending order as quickly as possible. This part assesses visual 
perception and psychomotor rapidity. TMT B assesses mental shifting and the participant’s attention 
ability, as they are required to do the same task as for TMT A, but alternating between numbers and 
letters. The participant is asked to perform the task as quickly as possible without lifting his/her pen 
from the paper. If the experimenter sees a mistake, she/he informs the participant. Results for both TMT 
A and B are reported as the number of seconds required to complete each task; therefore, higher scores 
reveal greater impairment. Trail A ≤ 40 seconds and Trail B ≤ 90 seconds are considered normal average 
values for these tests for older adults in the range of 60 to 75 years old. To index set shifting, the 

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difference between part B and part A completion times, smaller difference scores indicate better set 
shifting. [46]   
Digit Span Test WAIS-III (Forwards & Backwards) 
These tests measure short term and working memory. For the Digit Forward, participants are instructed 
to listen to each series of numbers in completion, followed by repeating the numbers in the same order. 
The final score is the sum of points from each correct trial. The maximum score is 16. For the Digit 
Backward, participants are instructed to listen to each series of numbers in completion, followed by 
repeating the numbers in the backward order. The final score is the sum of the points from each correct 
trial/series, with a maximum score of 14. The difference between the Digit Span Forward and Backward 
test scores is used as an index of the central executive component of working memory. Smaller 
difference scores indicate better working memory.[47,48]  
Boston Naming Test 
This test measures confrontational word retrieval skills. This version is composed by thirty pictures that 
are shown by the experimenter one by one. Participants are asked to name verbally each of the 15 nouns 
depicted in the black and white drawings. Following an error in naming, a semantic and/or phonemic 
cue is provided verbally to participants wherein the participants are given up to 20 seconds to respond 
following each cue. This task will be digitally recorded and stored. If the participant is not able to 
retrieve the name even after the semantic cue the experimenter gives a phonemic cue by speaking the 
part in bold (e.g. scroll; Experimenter says: “sc”).     
Generalized Anxiety Disorder 7 (GAD-7) 
The Generalized Anxiety Disorder 7 is a self-rated measure of anxiety symptoms and its score is 
calculated by rating 0, 1, 2, and 3 to the response categories of “not at all”, “several days”, “more than 
half the days” and “nearly every day”, respectively, and adding together the scores for the seven 
questions.  A score of 10 or higher has a sensitivity of 89% and a specificity of 82% for generalized 
anxiety disorder; a score of 5 is considered the cut-off for “mild” anxiety and 15 for “severe” anxiety.45 
Geriatric Depression Scale (GDS-30) 
The Geriatric Depression Scale was designed to discriminate the pattern of depressive symptoms from 
the general characteristics of the elderly population.  It is a brief 30-item questionnaire in which 
participants are asked to respond by answering yes or no in reference to how they felt over the past 
week.  The GDS was found to have a 92% sensitivity and a 89% specificity when evaluated against 
diagnostic criteria. Cut-off: normal-0-9; mild depressives-10-19; severe depressives-20-30.[49] 
Mini Mental State Examination (MMSE) 

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A 30 point questionnaire used to assess mental status.  The MMSE tests 5 areas of cognitive function: 
orientation, registration, attention and calculation, and recall and language.   
Montreal Cognitive Assessment Test (MoCA) 
The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild 
cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive 
functions, 
memory, 
language, 
visuoconstructional 
skills, 
conceptual 
thinking, 
calculations, 
and 
orientation. Time to administer the MoCA is approximately 10 minutes. The total possible score is 30 
points; a score of 26 or above is considered normal. [41] 
 
7.6.6 MOBILITY OUTCOMES  
 
Gait velocity and variability (single and dual-tasking) 
Gait velocity will be assessed as the time taken to walk the middle 6 meters of 8 meters using the 
Portable Walkway System (ProtoKinetic® and/or GAITRite® Systems, Inc.) These devices automate 
the acquisition, analysis, and reporting of the objective parameters of gait as the subject walks down the 
walkway with embedded sensors. As a result, these gait mats allow detecting subtle changes in gait, 
including gait variability since it has been proven to have a fine discrimination when compared with 
other quantitative methods.[50] The gait mat is located in a well-lit room with start and end points 
marked on the floor one meter from either end of the mat to avoid recording acceleration and 
deceleration phases.   
Instrumentation:  
Gait performance will be assessed using electronic walkway systems (GAITRite® or PkMas®), which 
automatically determines spatiotemporal gait parameters from imbedded sensors activated by foot 
pressure. A computer processes the footsteps, providing data for both spatial and temporal parameters.  
In addition, among sites without electronic walkway systems, quantitative gait parameters will be 
assessed using wearable inertial sensors (Gulf Coast Inc.; Shimmer Inc.) worn bilaterally on the ankles 
and at the hip.  Acceleration data will be used to calculate foot-contact and foot-off times determine step 
and stride timing data.  Overall gait velocity is determined by timing the standard walk distance.   
For walking conditions all individuals will perform walks along a 6 meter path while wearing hip and 
ankle worn accelerometers. Individuals will perform three main tasks: 1) preferred walking speed, 2) 
dual task walking and 3) fast walking. In the case that a participant uses an assistive aid (cane, walker), 
the tester will determine the participant’s capacity to walk safely without the use of the aid. With the 

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willingness of the participant, they will then perform one test walk without the use of the aid. If the 
participant is able to safely walk without the use of the assistive aid, all subsequent testing will be 
performed without its use. In all walks, participants will start 1 meter before the beginning of the 6 meter 
platform and continue to travel 1 meter past the end of the platform. This procedure is in place to ensure 
steady-state walking and to minimize any effects of acceleration and de-acceleration during the course 
of the walk. 
The first walking block will measure self-selected or preferred walking. Participants will be instructed to 
“walk at a comfortable and secure pace”. For preferred walking speed, a total of three walks will be 
performed. Participants with slow walking speed, less than 0.6m/s, or participants with lower limb 
disability, will be allowed to complete one walk if they are not able to perform the three trials. We 
require a minimum of approximately 20-steps to allow measurement of step-to-step variability. For 
example, an individual who walks at 1.5 m/s would usually only have 4-5 steps per walk. Therefore, we 
would need at least 3 repetitions. For those walking less than 1.0 m/s, two trials is commonly necessary. 
For those walking less than 0.5 m/s, a single walk is usually sufficient.  
The second walking block will be dual-task walking and includes three separate walks. Before 
performing the walking task, participants will enumerate out loud the verbal outputs will be performed 
from a seated position prior to any walks and recorded.  The seated assessments will be timed at 10 
seconds for dual-tasks and will be performed in the beginning of all cognitive assessments to prevent 
practice effects in dual-task gait performance (see order of assessments for visit 2, 3 and 4). If during the 
assessment time restriction appears or the assessor can see the tasks are difficult for the individual, the 
minimum gait assessment required will be usual gait, naming animals and Serial 7s.  The first dual-task 
administered will have the participant walk on the platform while simultaneously counting backward by 
serial 1’s from 100 (100-99-98…) out loud. The second dual-task will have the participant repeat the 
walk but this time, while naming animals (fluency test). In the third dual-task, the participant will be 
asked to walk the platform while subtracting 7’s from 100 (100-93-86…) out loud. During this trial, 
participants are encouraged to keep walking even if they cannot do the subtractions. These dual-task 
conditions selected are based on previous research which demonstrated that counting backwards requires 
both working memory and attention[51]. Participants will be instructed to pay attention to both gait and 
the cognitive task; if a participant stops either task during the trial, they will be prompted to continue. 
Not instructing to prioritize gait over cognitive task or vice-versa allows both gait and cognitive task to 
vary. This has previously been shown to provide a better representation of what happens naturally 
[52,53]. 
The 
evaluator 
will 
record 
any 
counting 
errors 
during 
walking.  

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The third and last walking block will include fast walking and the participants will be instructed to walk 
as fast and safe as they can without running. 
Six-minute Walking Test (6MWT) 
The 6MWT is used to quantitatively measure participants’ exercise capacity by measuring the maximum 
distance that a person can walk in 6 minutes. The test is a modification of the 12-min walk/run test 
originally developed by Cooper [54] and is commonly used as an assessment of exercise capacity. The 
6MWT is useful for predicting the maximal oxygen uptake related to cardiorespiratory fitness and is 
easily administered in clinical settings [55]. The 6MWT is believed to be a useful instrument because of 
its ease of administration and similarity to normal daily activities. It is a submaximal test of aerobic 
capacity which has been successfully used in MCI populations [56]. 
The 6MWT will be assessed by licensed and trained physical therapists. The participants are instructed 
to walk from one end of a 10-meter course to the other and back again as many times as possible in 6 
min, while under the supervision of a physical therapist. After each minute, participants were informed 
of the time elapsed and were given standardized encouragement. The distance (meters) walked in 6 min 
was recorded [55]. 
Short Physical Performance Battery (SPPB) 
It is a widely used instrument for quantifying lower extremity function and mobility in older adults. It is 
a group of measures that  combines the results  of the gait speed, chair stand and balance tests [57]. It 
has been used as a predictive tool for possible disability and can aid in the monitoring of function in 
older people. The scores range from 0 (worst performance) to 12 (best performance). The SPPB has 
been shown to have predictive validity showing a gradient of risk for mortality, nursing home 
admission, and disability. [58] 
 
7.6.7 
FUNCTIONAL 
OUTCOMES 
AND 
COMBINED 
SCORE 
OF 
COGNITION 
AND 
FUNCTIONALITY (POOLED INDEX) 
 
Functional Outcomes: Activities of daily living and everyday function will be evaluated using the use 
the ADCS which is a 23-item informant-rated questionnaire that measures, in a range of 0 to 78, an 
individual’s performance of activities of daily living.  
Pooled Index: A pool index including measures of cognition, mobility and functionality will be used as a 
secondary outcome. The cognitive decline seen with aging, due to neurodegenerative or vascular 
mechanisms, affects not only cognition but also mood, behavior and the ability to perform activities of 

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daily living. Therefore, treatments are considered successful if they slow down the progression of 
cognitive decline and maintain functionality and independency. Studies conducted in psychiatric patients 
and therapies for rheumatoid arthritis have demonstrated the applicability of a pooled index (PI) in 
measuring overall function and how changes in PI scores can be analyzed to quantify improvement or 
worsening conditions over time[60-62].  To apply this approach in our cohort, we constructed the 
Cognition and Functionality Pooled Index with six continuous variables sensitive to cognition 
function in older adults: Trail- Making Test, parts A and B (executive function), Rey Auditory Verbal 
Learning Test (RAVLT) (semantic memory, verbal learning), Geriatric Depression Scale [GDS] (mood), 
Alzheimer’s disease Activities of Daily Living-International Scale [ADL-IS] (functionality), and dual-
task gait cost.  The efficiency of a Pool Index is greatest when the combined variables are poorly 
correlated (r<0.4) which reduces variance of PI.  The suitability of our 6 source variables was confirmed 
by calculating the strength of pairwise correlations using Pearson Correlation Coefficient. The pooled 
index is created by converting all individual scores from the six tests to standardized z scores by 
subtracting the baseline group mean and dividing by the baseline group SD, and then averaging the 
standardized z scores. For tests with more than 1 component, the component scores were first averaged 
to create a single z score for each test (e.g., z scores for Trails A and B were averaged to create a single 
Trails z score) so that all tests were weighted equally, and then the mean z scores for the 6 tests was 
calculated.  
 7.6.8  QUALITY OF LIFE OUTCOMES 
Health related quality of life will be evaluated using the SF 36 that provides weightings for quality 
adjusted life year (QALYs). The SF 36 captures health states based on the following domains: 1) 
mobility; 2) self-care; 3) usual activities; 4) pain and 5) anxiety or depression. We will calculate scores 
using the established methodology to determine if there is a statistically significant difference in the 
incremental cost per QALY change across the 5 arms. 
7.6.9  HEALTH RESOURCE UTILIZATION 
At Visits 2 and 3, we will ask participants to report any visit to: 1) health care professionals; 2) 
admissions or visits to hospital; and 3) laboratory work using the health resource utilization 
questionnaire. This questionnaire has been previously described and supported in previous studies 
[Neumann PJ, Goldie SJ, Weinstein MC: Preference-based measures in economic evaluation in health 
care. Annual review of public health. 2000, 21: 587-611. 10.1146/annurev.publhealth.21.1.587.]. We 
will estimate total health care related costs over the 12 months from a Canadian health care system 

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perspective. Participants will be instructed to specify total health care expenditure and report the reason 
for each item. Additionally, participants will be instructed to report health care expenditure due to any 
adverse events associated with our study.  On a per participant basis, costs will be assigned to health 
care resource utilization using a fully allocated hospital cost model (for in-patient costs) and provincial 
guides to medical fees (for outpatient costs). Case analyses will consider the costs of all health care 
resource use and our sensitivity analyses will include only intervention related health care resource costs 
and a complete case analysis. 
8. ANALYSIS 
 
Analysis, planned analysis, frequency of analysis, and correction for multiple testing 
Analysis will be conducted as intention to treat and as per-protocol analysis. For the primary endpoint 
(ADAS-Cog plus), the change from baseline to six months and 12 months will be assessed using a 
repeated measures analysis of covariance (ANCOVA) model incorporating the baseline values as 
covariates. Observing a statistically significant difference in the primary outcome will be considered 
preliminary evidence of efficacy.  Additionally, reduction of prevalence rate of abnormal ADAS-Cog 
plus score (dichotomous variable) will be asses as a primary outcome. 
 We will also report variances, co-variances, and effect sizes, as well as sampling feasibility (i.e., ease of 
recruitment, recruitment rate, withdrawal rate).  Descriptive statistics for demographic and baseline 
characteristics will be provided with means and standard deviations, or medians and the interquartile 
range where appropriate, for continuous characteristics and frequencies and percentages for categorical 
variables.  
If the within-group comparison is statistically significant, Tukey’s multiple comparisons will identify 
significant pairwise differences. Similarly, for the secondary endpoints, six month changes in gait 
performance and secondary cognitive outcomes of interest will be performed using one way analyses of 
variance.  For group comparisons that are statistically significant, pairwise comparisons will be made 
using Tukey’s multiple comparisons tests.  All statistical tests will be two-tailed, and a p-value of less 
than 0.05 will be considered to indicate statistical significance. All calculations will be made using SPSS 
software package version 23.0 (SPSS Inc., Chicago, IL). 
Secondary analyses will be also performed according to an intention-to-treat principle and per protocol 
analysis. Frequency of the analyses: preliminary analysis will be performed at month 6 to ascertain 
descriptive characteristics at baseline assessment. Final efficacy analysis will be performed at the end of 
the trial since no safety issues are involved in this study. The statistical significance of the results will be 

CCNA MEC Team 
          
    Protocol Version: 15 February 2019 
30 
determined by Hochberg's variation of the Bonferroni procedure for multiple testing.39  An economical 
analysis will be also performed addressing health resources utilization. 
9. ADVERSE EVENT (AE) AND SERIOUS ADVERSE EVENT REPORTING (SAE) 
Adverse events will be recorded for subjects starting at the time of signing the Informed Consent and 
their discontinuation within the study.  All AEs will be recorded on an ongoing paper log, which will be 
reviewed by each site leader and forwarded to the team leader at London site, who will determine both 
the intensity of the event and the relationship of the event to study procedures.  Based on the outcome it 
will be up to the team leader to medically determine if it is justified for the participant to continue in the 
study or terminate their participation. 
SAEs will be recorded on a paper log, starting at the time of signing the Informed Consent and up to the 
end of their participation within the study.  SAEs which are classified as unanticipated will be reported 
to local REBs.  An SAE is defined as any incident that is unexpected, and related or possibly related to 
participation in the research study.  SAEs will be reviewed and monitored by each site team leader until 
resolved. 
9.1 CONCOMITANT MEDICATIONS 
Antacids (Magnesium-containing): Hypermagnesemia may develop when these agents are used 
concurrently with Vitamin D, particularly in patients with chronic renal failure. 
Anticonvulsants (Phenytoin, Phenobarbital): Decreased Vitamin D effects may occur when certain 
anticonvulsants are administered, as they may induce hepatic microsomial enzymes and accelerate the 
conversion of Vitamin D to inactive metabolites. 
Cholestyramine, Colestipol, Mineral Oil: Intestinal absorption of Vitamin D may be impaired. Patients 
on cholestyramine or colestipol should be advised to allow as much time as possible between the 
ingestion of these drugs and Vitamin D. 
Digoxin: Vitamin D should be used with caution in patients on digoxin as hypercalcemia (which may 
result with Vitamin D use) may precipitate cardiac arrhythmias. 
Thiazide diuretics: There is an increased risk of hypercalcaemia if vitamin D is coadministered with 
thiazide diuretics and calcium. Plasma-calcium concentrations should be monitored in patients receiving 
the drugs concurrently (Source: Martindale). 
Different Vitamin D analogues should be administered concurrently. 

CCNA MEC Team 
          
    Protocol Version: 15 February 2019 
31 
9.2 RESCUE MEDICATION AND RISK MANAGEMENT 
Higher doses of Vitamin D may lead to hypervitaminosis D manifested by hypercalcemia and its 
sequelae.  Treatment of acute or chronic intoxication includes withdrawal of Vitamin D3 and any 
calcium supplements, maintenance of a low calcium diet and if needed corticosteroids or calciuric 
diuretics, such as furosemide and ethacrymic acid to decrease serum calcium concentrations.  All 
participants will be monitored by site physicians and trained staff should any adverse events arise 
participants will have access to a phone number and e-mail address provided on the copy of their signed 
consent form. They will be informed to use these contacts to inform the Principal Investigator about 
concerns that may be associated with treatment received in each site.  
9.3 PREMATURE WITHDRAWAL/DISCONTINUATION CRITERIA 
Participants may be withdrawn or be discontinued from the study for any of the following reasons: 
1. At the participant’s request (withdrawal of consent) 
2. At the discretion of the investigator, if deemed appropriate, for any reason 
3. If an intolerable or life threatening adverse event occurs 
Or if any of the following develop: 
4. renal dysfunction 
5. dementia 
6. severe depression/anxiety/schizophrenia 
7. hypercalcaemia and/or hypermagnesemia 
Participant data collected to the date of discontinuation or withdrawal will be included in the analysis.  
10. ETHICAL CONSIDERATIONS 
This study will be conducted in compliance with the outlined protocol, International Conference on 
Harmonization Good Clinical Practice (ICH-GCP), and all applicable regulatory requirements.   
All relevant documents for this study will be submitted to the appropriate Research Ethics Board (REB) 
for review.  Written approval from the REB must be obtained prior to entering and testing participants 
within this study.  The REB will be notified of any protocol amendments regarding new study 
procedures which may occur during the course of the study.  Written approval from the REB on these 
amendments must be received prior to implementation of any new procedures. 

CCNA MEC Team 
          
    Protocol Version: 15 February 2019 
32 
10.1 CONFIDENTIALITY OF PARTICIPANT RECORDS 
Participants will be identified by a study identification number.  It will be necessary to collect the 
participants name and contact information as this study will require several scheduling procedures.  This 
information will be kept separate from the participant study identification number. 
11. ADMINISTRATIVE REQUIREMENTS  
11.1 PROTOCOL AMENDMENTS 
The leaders of the study, in collaboration with members of the team, may modify the protocol at any 
time during the study.  Protocol amendments will require REB approval prior to implementation of any 
changes. 
11.2 COMPLETION OF CASE REPORT FORMS (CRFS) 
All sites participating in his study will be trained on completion of CRFs.  The primary investigators at 
all sites are responsible for the CRFs with respect to completeness, accuracy, and clarity. 
11.3 MONITORING PROCEDURES  
All sites will use the same data collection forms to maintain consistency.  Monitoring procedures will be 
performed using the LORIS system platform for uploading data specially developed for the SYNERGIC 
study by CCNA informatics team platform. 
12. PUBLICATION POLICY 
The SYNERGIC Trial will follow CCNA publication policy. 
12.1 PARTICIPATING CENTERS 
The following centers will be participating in this study:  
 Gait and Brain Lab & Neurovascular Research Lab, The University of Western Ontario, London, 
ON 
 Imaging Research Laboratories. Robarts Research Institute, The University of Western Ontario, 
London, ON 
 Aging, Mobility, and Cognitive Neuroscience Lab, University of British Columbia, Vancouver, 
BC 
 Brain Research Centre, Centre for Hip Health and Mobility 

CCNA MEC Team 
          
    Protocol Version: 15 February 2019 
33 
 Unité de Neuroimagerie Fonctionnelle. Centre de recherche, Institut universitaire de gériatrie de 
Montréal, Université de Montréal, Montreal 
 Division of Geriatrics, McGill Centre of Excellence in Aging and Chronic Disease, McGill 
University 
 PERFORM Center, Concordia University/Centre de recherche, Institut universitaire de gériatrie 
de Montréal. Université de Montréal (CRIUGM) 
 Department of Psychology, Concordia University 
 Department of Medicine, Division of Neurology, University of Alberta 
 The Sun Life Financial Movement Disorders Research and Rehabilitation Centre, Wilfrid 
Laurier University 
 Centre for Community, Clinical and Applied Research Excellence (CCCARE), University of 
Waterloo 
 
Balance, Mobility and Falls Clinic at Toronto Rehab Rehabilitation Affiliate Network of the 
Centre for Stroke Recovery, Sunnybrook 
 
 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Enrollment 
Visit 1 (Screening) 
Letter of information 
MMSE; MoCA;PAR-Q 
Activity tracker for 1 week 
Excluded (n= ) 
 
Not meeting inclusion criteria 
(n= ) 
 
Declined to participate (n= ) 
 
Other reasons (n= )  
Visit 2 (Baseline) 
Cognitive Tests 
Gait and Balance Assessments 
MRI, blood draw 
 Randomized into 5 arms (n= ) 
 
E + CT+ Vit D  
 
E + CT+ pVit D  
 
 
E + cCT+ Vit D  
 
 
E + cCT+pVit D  
 
 
cE + cT + pVit D  
Visit 3 (6 month follow-up) 
Cognitive Tests 
Gait and Balance Assessments 
MRI, blood draw 
Telephone Follow-Up  
(9 month post-baseline) 
Figure 1: CONSORT flowchart for the SYNERGIC Trial 
Visit 4 (12 month follow-up) 
Cognitive Tests 
Gait and Balance Assessments 
Blood draw 

 
 
Figure 2. Schematic Timeline of Synergic Trial 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
(a) Recruitment of participants w ill be an on-going process w ith individuals being assigned to groups as they are enrolled. Recruitment period is expected to be 24 months, at a 
recruitment rate of 2.5 patients per month per main site (conservative estimate). How ever, recruitment may continue up to 36 months after the first individual has been recruited. 
Recruitment period of 24 months 
(b) Baseline assessments (T0) will be completed w ithin one-week of participant starting the specific intervention/placebo (i.e. month 0 for the first participant recruited; and month 30 for 
the last participant recruited). Participants w ill return to the clinic six months(c)  after starting the specific intervention/placebo (T6) to complete the post intervention assessment.  
Six months participants w ill return to the clinic again (T12) at w hich time their final assessment w ill be completed. The same assessments at T0 w ill be done. 
** 9 months after their first baseline assessment (T0) i.e. 3 months post-intervention, there w ill be a follow  up phone call. 
 
Month 
0 
Month 
24 
Month 
12 
Ongoing Recruitment a:for 12 mo (up to 18 mo) 
Analysis/ 
Write-up: 
Arm 2: Exercises, Control Cognitive Training, Placebo Vit D 
Arm 1: Exercises, Cognitive Training, Vit. D 
T0 Assessmentb 
1st participant recruited 
Arm 3: Exercises, Control Cognitive Training, Vit D 
Arm 4: Exercises, Control Cognitive Training, Placebo Vit. D 
T12 Follow-upd 
1st participant completed 
T6 Assessmentc 
20 w eek 
trial 
T0 Assessmentb 
For last participant recruited 
T12 Follow-upd 
For last participant recruited 
6 mo. 
follow -up 
Month 
36 
Arm 5: Control Exercise, Control Cognitive Training, Placebo Vit 

 
 
Figure 3. SYNERGIC Patient Flow Chart 
 
 
 
 
Recruitment of 
participant – 
identified/approved 
by REB (e.g. telephone 
recruit, referral 
through clinic visit, 
poster, etc.) 
Screening Visit (Visit 1) 
Review of study and written 
LOIC, Demographic Information 
Form, MMSE, MoCA, CDR, GDS-
30, GAD-7, PAR-Q +, PASE, 
ADCS-ADL + IADL, allocation of 
ActiGraph. 
 
Time: 3h 
Baseline Visit – T0 (Visit 2) 
Blood draw, Clinical Medical Questionnaire, Dual Task Control 
Assessment, 6MWT, SF-36, ADAS-Cog Plus Tests, Colour Word 
Interference Test, BNT, SPPB, Gait Testing. Schedule MRI 
appointment within one week of T0. Provide falls calendar. 
Time: 3h (including break if required) 
 
ActiGraph Data 
Collection 
Time: 7-10 consecutive 
days leading up to Visit 2 
T0 MRI 
Time: 1.25h 
Randomization 
Exercises + Cognitive Training + 
Vitamin D Supplementation 
*Visits over 5 months (20 weeks)  
*Participants must attend 80% of 
training sessions (48/60) 
*First day of training participant will 
receive Vitamin D/Placebo vials; these 
must be returned empty to trial staff 
with falls calendar on a monthly basis 
 
Time: 1.5h (3 times per week) 
6M Visit – T6 (Visit 3) 
Repeat all required 
assessments from Visit 1 and 
Visit 2, including blood draw. 
Schedule MRI appointment 
within one week of T6. Provide 
next 6 months of falls 
calendars + collect most recent 
fall calendar for study file. 
Time: 3.5h  
T6 MRI 
Time: 1.25h 
Telephone Follow-Up (9M 
post-baseline) 
To review falls calendars 
completed after T6. 
Time: 15 minutes  
12M Visit – T12 (Visit 4) 
Repeat all required assessments 
from Visit 1 and Visit 2. Collect 
 final falls calendars. 
 
Time: 3.5h 
Visit 1 to Visit 2: Up to 4 weeks 
Visit 2 to MRI: 1 week

 
 
13. Reference List 
 
 1.  Bherer L, Erickson KI, Liu-Ambrose T: Physical exercise and brain functions in older adults. J 
Aging Res 2013, 2013: 197326. 
 2.  Liu-Ambrose T, Nagamatsu LS, Voss MW, Khan KM, Handy TC: Resistance training and 
functional plasticity of the aging brain: a 12-month randomized controlled trial. Neurobiol 
Aging 2012, 33: 1690-1698. 
 3.  Colcombe S, Kramer AF: Fitness effects on the cognitive function of older adults: a meta-
analytic study. Psychol Sci 2003, 14: 125-130. 
 4.  Langlois F, Vu TT, Chasse K, Dupuis G, Kergoat MJ, Bherer L: Benefits of physical exercise 
training on cognition and quality of life in frail older adults. J Gerontol B Psychol Sci Soc Sci 
2013, 68: 400-404. 
 5.  Sage MD, Almeida QJ: A positive influence of vision on motor symptoms during sensory 
attention focused exercise for Parkinson's disease. Mov Disord 2010, 25: 64-69. 
 6.  Sage MD, Almeida QJ: Symptom and gait changes after sensory attention focused exercise vs 
aerobic training in Parkinson's disease. Mov Disord 2009, 24: 1132-1138. 
 7.  Cotman CW, Berchtold NC, Christie LA: Exercise builds brain health: key roles of growth 
factor cascades and inflammation. Trends Neurosci 2007, 30: 464-472. 
 8.  Nagamatsu LS, Handy TC, Hsu CL, Voss M, Liu-Ambrose T: Resistance training promotes 
cognitive and functional brain plasticity in seniors with probable mild cognitive impairment. 
Arch Intern Med 2012, 172: 666-668. 
 9.  Kueider AM, Parisi JM, Gross AL, Rebok GW: Computerized cognitive training with older 
adults: a systematic review. PLoS One 2012, 7: e40588. 
 10.  Reijnders J, van HC, van BM: Cognitive interventions in healthy older adults and people with 
mild cognitive impairment: a systematic review. Ageing Res Rev 2013, 12: 263-275. 
 11.  Li KZ, Roudaia E, Lussier M, Bherer L, Leroux A, McKinley PA: Benefits of cognitive dual-task 
training on balance performance in healthy older adults. J Gerontol A Biol Sci Med Sci 2010, 
65: 1344-1352. 
 12.  Ballesteros S, Prieto A, Mayas J, Toril P, Pita C, Ponce de LL et al.: Brain training with non-
action video games enhances aspects of cognition in older adults: a randomized controlled 
trial. Front Aging Neurosci 2014, 6: 277. 
 13.  Chapman SB, Aslan S, Spence JS, Hart JJ, Jr., Bartz EK, Didehbani N et al.: Neural mechanisms 
of brain plasticity with complex cognitive training in healthy seniors. Cereb Cortex 2015, 25: 
396-405. 

 
 
 14.  Annweiler C, Montero-Odasso M, Muir SW, Beauchet O: Vitamin D and Brain Imaging in the 
Elderly: Should we Expect Some Lesions Specifically Related to Hypovitaminosis D? Open 
Neuroimag J 2012, 6: 16-18. 
 15.  Beauchet O, Annweiler C, Verghese J, Fantino B, Herrmann FR, Allali G: Biology of gait control: 
Vitamin D involvement. Neurology 2011, 76: 1617-1622. 
 16.  Muir SW, Montero-Odasso M: Effect of vitamin D supplementation on muscle strength, gait 
and balance in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 2011, 59: 
2291-2300. 
 17.  Annweiler C, Schott AM, Rolland Y, Blain H, Herrmann FR, Beauchet O: Dietary intake of 
vitamin D and cognition in older women: a large population-based study. Neurology 2010, 75: 
1810-1816. 
 18.  Annweiler C, Schott AM, Berrut G, Chauvire V, Le Gall D, Inzitari M et al.: Vitamin D and 
ageing: neurological issues. Neuropsychobiology 2010, 62: 139-150. 
 19.  Annweiler C, Montero-Odasso M, Llewellyn DJ, Richard-Devantoy S, Duque G, Beauchet O: 
Meta-analysis of memory and executive dysfunctions in relation to vitamin D. J Alzheimers Dis 
2013, 37: 147-171. 
 20.  Annweiler C, Muir SW, Nabeel S, Gopaul K, Beauchet O, Montero-Odasso M: Higher serum 
vitamin D concentration is associated with better balance in older adults with supra-optimal 
vitamin D status. J Am Geriatr Soc 2013, 61: 163-165. 
 21.  Ostbye T, Crosse E: Net economic costs of dementia in Canada. CMAJ 1994, 151: 1457-1464. 
 22.  Toronto 
Rehabilitation 
Institute. 
Fact 
Sheet: 
Disabilities 
and 
aging 
in 
Canada. 
http://www.torontorehab.com/research/documents/iDAPT-Fact%20Sheet-
%20Disabilities%20in%20Canada.pdf . 8-26-2009.  
Ref Type: Electronic Citation 
 23.  Ohman H, Savikko N, Strandberg TE, Pitkala KH: Effect of physical exercise on cognitive 
performance in older adults with mild cognitive impairment or dementia: a systematic 
review. Dement Geriatr Cogn Disord 2014, 38: 347-365. 
 24.  Suzuki T, Shimada H, Makizako H, Doi T, Yoshida D, Ito K et al.: A randomized controlled trial 
of multicomponent exercise in older adults with mild cognitive impairment. PLoS One 2013, 8: 
e61483. 
 25.  Skinner J, Carvalho JO, Potter GG, Thames A, Zelinski E, Crane PK et al.: The Alzheimer's 
Disease Assessment Scale-Cognitive-Plus (ADAS-Cog-Plus): an expansion of the ADAS-Cog 
to improve responsiveness in MCI. Brain Imaging Behav 2012, 6: 489-501. 
 26.  Takeda A, Loveman E, Clegg A, Kirby J, Picot J, Payne E et al.: A systematic review of the 
clinical effectiveness of donepezil, rivastigmine and galantamine on cognition, quality of life  
and adverse events in Alzheimer's disease. Int J Geriatr Psychiatry 2006, 21: 17-28. 

 
 
 27.  Crane PK, Carle A, Gibbons LE, Insel P, Mackin RS, Gross A et al.: Development and 
assessment of a composite score for memory in the Alzheimer's Disease Neuroimaging 
Initiative (ADNI). Brain Imaging Behav 2012, 6: 502-516. 
 28.  Albert MS, DeKosky ST, Dickson D, Dubois B, Feldman HH, Fox NC et al.: The diagnosis of 
mild cognitive impairment due to Alzheimer's disease: recommendations from the National 
Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for 
Alzheimer's disease. Alzheimers Dement 2011, 7: 270-279. 
 29.  Lawton MP, Brody EM: Assessment of older people: self-maintaining and instrumental 
activities of daily living. Gerontologist 1969, 9: 179-186. 
 30.  American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (4th ed. 
- Text Revision; [DSV-IV-TR]). Washington, DC: Author; 2000. 
 31.  Fiatarone Singh MA, Gates N, Saigal N, Wilson GC, Meiklejohn J, Brodaty H et al.: The Study of 
Mental and Resistance Training (SMART) study-resistance training and/or cognitive training 
in mild cognitive impairment: a randomized, double-blind, double-sham controlled trial. J Am 
Med Dir Assoc 2014, 15: 873-880. 
 32.  Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E: Training effects on dual-
task performance: are there age-related differences in plasticity of attentional control? 
Psychol Aging 2005, 20: 695-709. 
 33.  Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E: Testing the limits of 
cognitive plasticity in older adults: application to attentional control. Acta Psychol (Amst) 
2006, 123: 261-278. 
 34.  Bherer L, Kramer AF, Peterson MS, Colcombe S, Erickson K, Becic E: Transfer effects in task-
set cost and dual-task cost after dual-task training in older and younger adults: further 
evidence for cognitive plasticity in attentional control in late adulthood. Exp Aging Res 2008, 
34: 188-219. 
 35.  Vieth R: The mechanisms of vitamin D toxicity. Bone Miner 1990, 11: 267-272. 
 36.  Vieth R, Chan PC, MacFarlane GD: Efficacy and safety of vitamin D3 intake exceeding the 
lowest observed adverse effect level. Am J Clin Nutr 2001, 73: 288-294. 
 37.  Venning G: Recent developments in vitamin D deficiency and muscle weakness among elderly 
people. BMJ 2005, 330: 524-526. 
 38.  Lussier M, Brouillard P, Bherer L: Limited Benefits of Heterogeneous Dual-Task Training on 
Transfer Effects in Older Adults. J Gerontol B Psychol Sci Soc Sci 2015. 
 39.  Stanziano DC, Roos BA, Perry AC, Lai S, Signorile JF: The effects of an active-assisted 
stretching program on functional performance in elderly persons: a pilot study. Clin Interv 
Aging 2009, 4: 115-120. 
 40.  Julayanont P, Brousseau M, Chertkow H, Phillips N, Nasreddine ZS: Montreal Cognitive 
Assessment Memory Index Score (MoCA-MIS) as a predictor of conversion from mild 
cognitive impairment to Alzheimer's disease. J Am Geriatr Soc 2014, 62: 679-684. 

 
 
 41.  Nasreddine ZS, Phillips NA, Bedirian V, Charbonneau S, Whitehead V, Collin I et al.: The 
Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. 
J Am Geriatr Soc 2005, 53: 695-699. 
 42.  Vakil E, Greenstein Y, Blachstein H: Normative data for composite scores for children and 
adults derived from the Rey Auditory Verbal Learning Test. Clin Neuropsychol 2010, 24: 662-
677. 
 43.  Rey A: L'examen clinique en psychologie. 1958. 
 44.  Schmidt M: Rey auditory verbal learning test: A handbook. Western Psychological Services Los 
Angeles; 1996. 
 45.  Strauss E, Sherman EM, Spreen O. A compendium of neuropsychological tests.  2006.  New York: 
Oxford University Press.  
Ref Type: Generic 
 46.  Tombaugh TN: Trail Making Test A and B: normative data stratified by age and education. 
Arch Clin Neuropsychol 2004, 19: 203-214. 
 47.  Yamamoto D, Kazui H, Takeda M: [Wechsler Adult Intelligence Scale-III (WAIS-III)]. Nihon 
Rinsho 2011, 69 Suppl 8: 403-407. 
 48.  Liu-Ambrose T, Nagamatsu LS, Graf P, Beattie BL, Ashe MC, Handy TC: Resistance training 
and executive functions: a 12-month randomized controlled trial. Arch Intern Med 2010, 170: 
170-178. 
 49.  Yesavage JA, Brink TL, Rose TL, Lum O, Huang V, Adey M et al.: Development and validation 
of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1982, 17: 37-49. 
 50.  Shore WS, deLateur BJ, Kuhlemeier KV, Imteyaz H, Rose G, Williams MA: A comparison of gait 
assessment methods: Tinetti and GAITRite electronic walkway. J Am Geriatr Soc 2005, 53: 
2044-2045. 
 51.  Hittmair-Delazer M, Semenza C, Denes G: Concepts and facts in calculation. Brain 1994, 117 ( 
Pt 4): 715-728. 
 52.  Verghese J, Kuslansky G, Holtzer R, Katz M, Xue X, Buschke H et al.: Walking while talking: 
effect of task prioritization in the elderly. Arch Phys Med Rehabil 2007, 88: 50-53. 
 53.  Yogev-Seligmann G, Hausdorff JM, Giladi N: The role of executive function and attention in 
gait. Mov Disord 2008, 23: 329-342. 
 54.  Cooper KH: A means of assessing maximal oxygen intake: correlation between field and 
treadmill testing. JAMA 1968, 203: 201-204. 
 55.  Steffen TM, Hacker TA, Mollinger L: Age- and gender-related test performance in community-
dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, 
and gait speeds. Phys Ther 2002, 82: 128-137. 

 
 
 56.  Makizako H, Shimada H, Doi T, Park H, Yoshida D, Suzuki T: Six-Minute Walking Distance 
Correlated with Memory and Brain Volume in Older Adults with Mild Cognitive 
Impairment: A Voxel-Based Morphometry Study. Dementia and Geriatric Cognitive Disorders 
Extra 2013, 3: 223-232. 
 57.  Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV et al.: Lower extremity 
function and subsequent disability consistency across studies, predictive models, and value of 
gait speed alone compared with the Short Physical Performance Battery. The Journals of 
Gerontology Series A: Biological Sciences and Medical Sciences 2000, 55: M221-M231. 
 58.  Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG et al.: A short 
physical performance battery assessing lower extremity function: association with self-
reported disability and prediction of mortality and nursing home admission. J Gerontol 1994, 
49: M85-M94. 
 59.  Lord SR, Menz HB, Tiedemann A: A physiological profile approach to falls risk assessment and 
prevention. Phys Ther 2003, 83: 237-252. 
 60.  Speechley M, Barton JC, Passmore L, Harrison H, Reboussin DM, Harris EL et al.: Potential 
nonresponse bias in a clinical examination after initial screening using iron phenotyping and 
HFE genotyping in the hemochromatosis and iron overload screening study. Genet Test Mol 
Biomarkers 2009, 13: 721-728. 
 61.  Smythe HA, Helewa A, Goldsmith CH: "Independent assessor" and "pooled index" as 
techniques for measuring treatment effects in rheumatoid arthritis. J Rheumatol 1977, 4: 144-
152. 
 62.  Goldsmith CH, Smythe HA, Helewa A: Interpretation and power of a pooled index. J Rheumatol 
1993, 20: 575-578. 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
APPENDIX I 
 
 
Visit Table 
Procedure 
Visit 1 
Screening 
Visit 2 
Baseline 
 
Randomization 
Visit 3 
6M Visit 
Telephone 
Follow-up (9M 
post-Baseline) 
Visit 4 
12M Visit 
Written Informed Consent 
X 
 
 
 
 
 
Demographic Information 
X 
 
 
 
 
PASE Questionnaire 
X 
 
X 
 
X 
Mini Mental State 
Examination (MMSE) 
X 
 
 
 
 
Montreal Cognitive 
Assessment (MoCA) 
Logical Memory 1 & 2 * 
CERAD Word List Recall * 
X 
 
X 
 
X 
Geriatric Depression Scale 
(GDS-30) 
X 
 
X 
 
X 
Generalized Anxiety Disorder 
7 (GAD-7) 
X 
 
X 
 
X 
Clinical Dementia Rating 
(CDR) 
X 
 
X 
 
X 
Physical Activity Readiness 
Questionnaire Plus (PAR-Q +) 
X 
 
 
 
 
ADCS-ADL and IADL 
X 
 
X 
 
X 
Clinical Medical 
Questionnaire 
 
X 
X 
 
X 
Dual Task Control Assessment 
 
X 
X 
 
X 
Six Minute Walk Test 
(6MWT) ^ 
 
X 
X 
 
X 
Quality of Life Questionnaire 
(SF-36) 
 
X 
X 
 
X 
ADAS-Cog 13 (+ tests **) 
 
X 
X 
 
X 
Digit Span Forward and 
Backward WAIS-III ** 
 
X 
X 
 
X 
TMT A and B ** 
 
X 
X 
 
X 
Digit Symbol Test ** 
 
X 
X 
 
X 
Boston Naming Test ** 
 
X 
X 
 
X 
Colour Word Interference Test 
 
X 
X 
 
X 
Envelope Test 
 
X 
X 
 
X 
Short Physical Performance 
Battery (SPPB) 
 
X 
X 
 
X 
Gait Assessment using Gait 
Mat and accelerometers (when 
available) 
 
X 
X 
 
X 
Neuroimaging (MRI) 
 
X 
X 
 
 
Blood Draw 
 
X 
X 
 
X 
Falls Calendar ^^ 
 
X 
X 
X 
X 
 
* These tests are implemented to harmonize with inclusion criteria for COMPASS-ND and are not mandatory if the 
MoCA score ≤ 24.  
** Testing included in the ADAS Cog Plus.  
^ 6MWT can be completed at the Baseline Visit or at Day 1 of intervention sessions at the gym facilities. Please note date 
and location of the 6MWT in patient file. 
^^ Calendar will be given to participant to complete and will be submitted to Research Staff at exercise training. 

 
 
 
 

SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
1
 
1 
 
2 
 
3 
 
4 
 
5 
 
6 
 
7 
Statistical Analysis Plan 
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(SAP) 
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SYNchronizing Exercises, Remedies in GaIt and Cognition (SYNERGIC) Trial 
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Version: 
Final 
Authors: 
Manuel Montero-Odasso, MD, PhD, University of Western Ontario 
Surim Son, PhD(c), University of Western Ontario 
Yanina Sarquis-Adamson, PhD, Parkwood Institute 
Guangyong Zou, PhD, University of Western Ontario and Robarts 
Research Institute 
Mark Speechley, PhD, University of Western Ontario  
Date: 
Sept 2022 
 
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SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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1. Introduction 
31 
The SYNERGIC TRIAL (SYNchronizing Exercises, Remedies in GaIt and Cognition) is 
32 
a randomized, phase II, fractional factorial, five-arm, double-blind controlled study 
33 
evaluating the effect of aerobic-resistance exercise with and without cognitive training 
34 
and vitamin D supplementation on cognitive function.  
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Specifically, physical exercise is a progressive and supervised aerobic (AE) and 
36 
resistance training (RT) program tailored for older adults’ physical capabilities. 
37 
Computerized cognitive training will be delivered using the Neuropeak cognitive training 
38 
program designed to target working memory and attention. Vitamin D supplementation 
39 
will be delivered in capsules with 10,000 IU, 3 times per week, reaching a weekly dose 
40 
of 30000 IU. Control interventions will be sham cognitive training, balance and toning 
41 
exercise (BAT), and matching vitamin D placebo capsules. 
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43 
2. Study Objectives 
44 
To evaluate: 
45 
Objective 1 The effect of supervised aerobic-resistance exercise on cognitive function 
46 
Hypothesis 1. Twenty weeks of supervised aerobic-resistance exercise will significantly 
47 
improve cognitive function in older adults with MCI, as assessed by primary outcome 
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Alzheimer’s Disease Assessment Scale-Cognitive (ADAS-Cog 13 and plus variant) and 
49 
secondary outcomes, compared to a balance and toning (BAT) control. 
50 
Objective 2. The effect of adding cognitive training to aerobic-resistance exercise on 
51 
cognitive function.  
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Hypothesis 2. Adding cognitive training to aerobic-resistance exercise will significantly 
53 
improve primary and secondary outcomes compared to aerobic-resistance exercise 
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without cognitive training. 
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Objective 3. The effect of adding vitamin D supplementation to aerobic-resistance 
56 
exercise on cognitive function. 
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Hypothesis 3. Adding vitamin D supplementation in weekly dose of 30000 IU to 
58 
aerobic-resistance exercise will significantly improve primary and secondary outcomes 
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compared to aerobic-resistance exercise without vitamin D supplementation. 
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Objective 4. The effect of multi-domain intervention (aerobic-resistance exercise + 
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cognitive training + Vitamin D supplementation) on cognitive function. 
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Hypothesis 4. The multi-domain intervention (aerobic-resistance exercise + cognitive 
63 
training + vitamin D supplementation) will significantly improve primary and secondary 
64 
outcomes compared to the control intervention. 
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SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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66 
3. Study Population 
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We will target older adults aged 60 to 85 years old with mild cognitive impairment (MCI).  
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4. Study Design  
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This is a Phase II, randomized, double-blind, five-arm controlled trial. The trial design 
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follows a fractional factorial design as shown in Figure 1. Participants will be recruited 
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primarily from the community and from clinics serving MCI population across five sites: 
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London (lead and sponsor site), Waterloo-University of Waterloo, Waterloo-Wilfrid 
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Laurier University, Montreal, and Vancouver. All eligible participants will be randomized 
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to 5 arms in 1:1:1:1:1 ratio: 
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Arm 1: combined AE and RT exercise + cognitive training + vitamin D 
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Arm 2: combined AE and RT exercise + cognitive training + placebo vitamin D 
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Arm 3: combined AE and RT exercise + control cognitive training + vitamin D 
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Arm 4: combined AE and RT exercise + control cognitive training+ placebo vitamin D 
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    Arm 5: BAT exercise + control cognitive training + placebo vitamin D 
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Figure 1. Trial design overview 
83 
5. Study Endpoint 
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The study endpoint will be at 6 Month (post-intervention). 
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86 
6. Study Assessment 
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The participant’s eligibility will be assessed during the screening visit. Assessment 
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which will be performed during three visits: baseline, post-intervention at 6 months, and 
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6-month follow up after the postintervention at 12 months. The measures at each 
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assessment are described in Table 1. 
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Table 1. Assessments across study visits 
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Procedure 
Visit 1 
Screening
Visit 2 
Baseline
Visit 3 
6 month 
Telephone 
Follow-up at 
9 month 
Visit 4 
12 month
Written Informed Consent 
X 
Demographic Information  
X 
Mini Mental State Examination (MMSE)  
X 
Physical Activity Readiness Questionnaire Plus (PARQ +) 
X 
Logical Memory 1 & 2  
X 
CERAD Word List Recall  
X 
PASE Questionnaire  
X 
Montreal Cognitive Assessment (MoCA)  
X 
X 
X 
Generalized Anxiety Disorder 7 (GAD-7)  
X 
X 
X 
Geriatric Depression Scale (GDS-30)  
X 
X 
X 
Clinical Dementia Rating (CDR)  
X 
X 
X 
Activities of Daily Living (ADCS-ADL and IADL)  
X 
X 
X 
Clinical Medical Questionnaire  
X 
X 
X 
Dual Task Control Assessment  
X 
X 
X 
ADAS-Cog 13 (+ tests a)  
X 
X 
X 
Trail Making Test A & Ba  
X 
X 
X 
Digit Symbol Test a  
X 
X 
X 
Digit Span Forward and Backward WAIS-III a  
X 
X 
X 
Boston Naming Test a 
X 
X 
X 
Verbal Fluency Test a  
X 
X 
X 
Colour Word Interference Test  
X 
X 
X 
Quality of Life Questionnaire (SF-36)  
X 
X 
X 
Short Physical Performance Battery (SPPB)  
X 
X 
X 
Gait Assessment using Gait Mats and accelerometers 
(when available)  
X 
X 
X 
Six Minute Walk Test (6MWT)b 
X 
X 
X 
Neuroimaging (MRI) 
Blood Draw 
X 
X 
Falls Calendarc 
X 
X 
X 
X 
aTesting included in the ADAS-Cog plus 
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bThis test may be completed at the gym facility on the first day of intervention 
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cCalendar will be given to participant to complete and will be submitted to Research Staff at exercise training 
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7. Determination of Sample Size 
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Sample size calculation is based on changes in our primary outcome: global cognitive 
98 
function measured using the Alzheimer Disease Assessment Scale Cognitive 13 and 
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the plus variant (ADAS-Cog 13 and plus). A target sample of 200 participants (40 per 
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arm) was determined based on 80% power to detect either main effects or an 
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interaction of at least a moderate (Cohen’s d ~0.5)1 effect size of changes in the ADAS-
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Cog-13.2 The final sample size accounted for a 15% attrition. 
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8. Primary Outcomes 
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Primary outcome will be changes in cognitive function measured with the ADAS-Cog 13 
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items (ADAS-Cog-13) and the plus variant (ADAS-Cog-plus) at endpoint, 6 Month. 
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Improvement at endpoint in either variant is considered evidence of efficacy.  
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8.1 Change in cognitive function on ADAS-Cog-13 at post-intervention (Month 6) 
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The ADAS-Cog 13 consists of 13 brief cognitive tests assessing memory, language, 
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attention, concentration and praxis. The individual tests are listed in Table 2. Scores 
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range from 0 to 84, with higher scores indicating severe cognitive impairment.  
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8.2 Change in cognitive function on ADAS-Cog-Plus at post-intervention (Month 6) 
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Four additional tests focusing on executive function will be added to the ADAS-Cog 13 
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to comprise the plus variant3 (Table 2). Scores will be transformed into an algorithm 
115 
validated by Crane et al.4 The higher scores will indicate severe of cognitive impairment.  
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Table 2. Individual tests included in the ADAS-Cog 
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ADAS-Cog-13 
ADAS-Cog-Plus 
Word recall 
Word recall 
Delayed word recall 
Delayed word recall 
Following commands 
Following commands 
Constructional praxis 
Constructional praxis 
Ideational praxis 
Ideational praxis 
Naming objects 
Naming objects 
Orientations 
Orientations 
Word recognition 
Word recognition 
Remembering instructions 
Remembering instructions 
Comprehension 
Comprehension 
Word finding 
Word finding 
Spoken language 
Spoken language 
Number cancellation 
Number cancellation 
 
Trial Making A and B 
 
Digit symbol substitution 
 
WAIS III digit forward and backward 
 
Category fluency – Animals and Vegetable 

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9. Secondary Outcomes* 
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Secondary outcomes include neuropsychological assessments, gait and mobility 
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outcomes (including incidence of fall), neuroimaging, and blood biomarkers. *Note that 
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secondary outcomes will be not reported in the primary manuscript. 
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9.1 Change in cognitive function on neuropsychological tests 
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The secondary cognitive outcomes will include:  
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a) Montreal Cognitive Assessment test for global cognition  
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b) The ADAS-Cog Recall word list for verbal semantic memory  
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c) Trail Making Test A and B  
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d) Digit Symbol Substitution Test  
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e) Digit Span Test Forward and Backwards  
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f) Boston Naming Test 
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g) Verbal fluency Animals and Vegetables 
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9.2 Change in gait performance 
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Gait performance will be evaluated using gait speed and gait variability under single and 
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dual-tasking. Gait speed will be measured as the time taken to walk 6 m using an 
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electronic walkway system (ProtoKinetic® and/or GAITRite® Systems, Inc.). Gait 
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variability of spatial and temporal gait variables (stride time, stride length, double 
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support time and step width) will be calculated using the coefficient of variation (CV = 
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(standard deviation / mean) ×100). 
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9.3 Change in mobility and falls 
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Mobility will be measured with the Short Physical Performance Battery (SPPB), and the 
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6 min walk test (6MWT).  
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A fall will be defined as ‘unintentionally coming to rest on the ground, floor, or other 
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lower level and not due to a seizure, syncope, or an acute stroke’. Recurrent falls are 
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defined as ‘two or more events in a 12-month period’. Falls will be recorded throughout 
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the 12-month trial, participants will be provided with a falls calendars, on which they will 
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record any falls that have occurred, and they will be asked to bring them monthly to the 
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training sessions to review with a research staff member. After the completion of the 
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intervention, participants will be contacted at month 9 and 12 to report incidental falls. 
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9.4 Change in Neuroimaging 
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Pre-post regional patterns of brain plasticity will be assessed using structural (high-
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resolution 3D T1-weighted images = 7 min) in order to get voxel-based volumetric and 
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cortical thickness measures, as well as diffusion tensor imaging (DTI, 30 directions, with 
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SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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AP/PA correction scan = 7 min) to calculate fractional anisotropy and diffusivity in white 
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matter tracts as well as derive tract-based statistics. Cerebrovascular integrity and 
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pathology will be assessed using the following contrasts: PD/T2 = 5 min; FLAIR = 7 min, 
155 
and T2* = 5 min). Functional magnetic resonance imaging at rest (rsfMRI plus field map 
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= 12 min) will also be acquired to measure change in data-driven functional networks. 
157 
9.5 Change in Blood biomarkers measures 
158 
Serum biomarkers of inflammation (C reactive protein, and interleukin 6), neuroplasticity 
159 
(brain-derived neurotropic factor), endothelial health (vascular endothelial growth factor 
160 
1), and vitamin D serum levels will be measured before and after intervention. 
161 
9.6 Covariates 
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Pre-specified covariates will be age, sex, years of education and number of 
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comorbidities. 
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10. 
Statistical Analysis 
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10.1 Descriptive Analysis 
167 
The baseline characteristics will be summarized using means and standard deviation, or 
168 
medians and interquartile range where appropriate, for continuous characteristics, and 
169 
frequencies and percentages for categorical variable. 
170 
10.2 Primary Efficacy Analysis  
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The primary analysis will be based on the intention-to-treat principle, including everyone 
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who were randomized. Comparisons between arms will be conducted according to pre-
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specifications in the protocol. These comparisons align well with the recommended 
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analysis and reporting of factorial trials5, which used “inside the table” and “at the 
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margin” analyses for different comparisons. The “inside the table” analysis will be used 
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to compare each intervention effect to control, while “at the margins” analysis will be 
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used to assess the effect of adding intervention. 
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The major interest would be the effect of the intervention on change in primary 
179 
outcomes at 6 Month compared to the control arm (arm 5). The primary outcome 
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measure of mean change in ADAS-Cog-13 and ADAS-Cog-Plus scores will be analyzed 
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using a linear mixed model with restricted likelihood estimation. The model will be fitted 
182 
with participant-specific random intercept and fixed effects of time, intervention arm, and 
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time x intervention arm interaction. The time variable will be used as a categorical 
184 
variable (0 = baseline; 1 = Month 6.) The intervention arm variable will be dummy 
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coded, using the control group as a reference category. The interaction term will be 
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used to assess between-group differences (representing a mean difference in change in 
187 
cognitive scores over time between two groups). With dummy coding of the intervention 
188 
arm, the interaction term will allow to compare the mean change in each intervention 
189 
arm to the arm 5 (control). The within-group difference (representing a mean change in 
190 
cognitive scores over time within the group) will be measured with marginalized mean 
191 
from the linear mixed regression model. The model will be further adjusted for 
192 
participant characteristics including age, sex, education, and comorbidities. 
193 
An unstructured covariance matrix will be used for all models. The model assumption 
194 
will be assessed using the normal quantile plots of residuals for normality and the 
195 
residuals vs. fitted plot for variance homogeneity. If the assumptions are not fully met, 
196 
the data will be transformed (i.e., log). Missing data will not be imputed and will be 
197 
assumed to be missing at random, as the mixed model approach is well-known to 
198 
handle such data effectively.6 The baseline data from individuals who did not complete 
199 
Month 6 assessment will be included in the linear mixed model.  
200 
The mean difference between groups will be presented with their 95% CI and p-value, 
201 
while the mean change within group will be presented with their standard error. The 
202 
obtained marginalized mean and standard deviation will be used to calculate the effect 
203 
size (
௠௘௔௡ ௖௛௔௡௚௘ ௜௡ ௧௥௘௔௧௠௘௡௧ ௑ ି ௠௘௔௡ ௖௛௔௡௚௘ ௜௡ ௧௥௘௔௧௠௘௡௧ ௒
௣௢௢௟௘ௗ ௦௧௔௡ௗ௔௥ௗ ௗ௘௩௜௔௧௜௢௡ ௢௙ ௖௛௔௡௚௘
). As outlined in our published 
204 
protocol, we will calculate the proportion of participants with improvement in primary 
205 
outcomes. 
206 
All tests will be two-sided, and p-value of less than 0.05 will be considered as 
207 
statistically significant. Adjustments for multiple comparisons will not be made as the 
208 
trial is intended to compare the intervention effect to the control rather than pairwise.7 
209 
Per-protocol analysis will be performed as well. 
210 
As per recommended analyses of fractional factorial design8, “at the margin” analyses 
211 
will be performed by collapsing arms according to the pre-specified comparison. 
212 
Collapsing intervention arms allow to increase the study power to detect the difference 
213 
in effect. More details are provided below for each pre-specified comparison.  
214 
10.2.1 Effect of aerobic-resistance exercise 
215 
To address objective 1 (the effect of supervised aerobic-resistance exercise on 
216 
cognitive function), the intervention arms providing exercise intervention (arm 1 to 4) will 
217 
be collapsed as one category and compared to the control (arm 5). The new 
218 
independent variable will be created to represent exercise intervention: aerobic-
219 
resistance exercise intervention (collapsed arm 1 to 4), and control exercise intervention 
220 
– BAT –  (arm 5).  The new intervention variable will be fitted into the same linear mixed 
221 
model described above. Using the interaction between exercise intervention x time, the 
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change in primary outcome will be contrasted between participants receiving the 
223 
aerobic-resistance exercise and those not receiving the aerobic-resistance exercise.  
224 
10.2.2 Effect of adding cognitive training 
225 
The objective 2 (the effect of adding cognitive training to aerobic-resistance exercise on 
226 
cognitive function) will be examined by pooling the intervention arms providing both 
227 
exercise and cognitive intervention (arm 1 and 2) and pooling the intervention arms 
228 
providing exercise intervention but not cognitive intervention (arm 3 and 4). A new 
229 
independent variable will be created for addition of cognitive training: both exercise and 
230 
cognitive intervention (pooled arm 1 and 2) and exercise but no cognitive intervention 
231 
(pooled arm 3 and 4). Using the interaction term in the linear mixed model, the contrast 
232 
will be made between the two collapsed arms to assess whether the effect of adding 
233 
cognitive training to aerobic-resistance exercise differ from aerobic-resistance exercise.  
234 
If there is a significant difference observed, the two collapsed arms will be compared to 
235 
the control arm (arm 5). This marginal analysis will allow to evaluate the main effect of 
236 
aerobic-resistance exercise alone (pooled arm 1 and 2) and aerobic-resistance exercise 
237 
with cognitive training (pooled arm 3 and 4) compared to the control (arm 5) with higher 
238 
power (as a result of increase in sample size).5,8 
239 
10.2.3 Effect of adding vitamin D supplements 
240 
The objective 2 (the effect of adding vitamin D to aerobic-resistance exercise on 
241 
cognitive function) will be examined by pooling the intervention arms providing both 
242 
exercise and vitamin D intervention (arm 1 and 3) and pooling the intervention arms 
243 
providing exercise intervention but not vitamin D (arm 2 and 4). A new independent 
244 
variable will be created to represent addition of vitamin D: both aerobic-resistance 
245 
exercise and vitamin D intervention (pooled arm 1 and 3) and aerobic-resistance 
246 
exercise but no vitamin D intervention (pooled arm 2 and 4). The linear mixed model will 
247 
be repeated using this new independent variable and the two pooled arms will be 
248 
compared. This will allow to explore whether adding vitamin D to aerobic-resistance 
249 
exercise improve the outcome compared to the aerobic-resistance exercise. If a 
250 
significant difference is observed, the two pooled arms will be compared to the control 
251 
arm (arm 5) to assess the main effect. 
252 
10.2.4 Effect of multidomain intervention 
253 
The objective 4 (effect of multi-domain intervention (aerobic-resistance exercise + 
254 
cognitive training + Vitamin D supplement) on cognitive function) will be assessed using 
255 
the time x intervention arm interaction fitted in the linear mixed model in section 10.2. 
256 
The interaction term between time x intervention arm 1 will represents the effect of 
257 
multidomain intervention (arm 1) compared to the control (arm 5). 
258 

SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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10.2.5 Long-term effect: From Baseline and Post-intervention to Follow up 
259 
The long-term intervention effect from baseline and post-intervention to follow-up 
260 
(Month 12) will be assessed using the linear mixed model. Time will be used as a 
261 
categorical variable (Baseline, Month 6, and Month 12). Individuals with incomplete 
262 
follow up assessments will still be included in the linear mixed model. 
263 
10.2.6 Post-hoc analyses 
264 
ADAS-Cog-Plus is a construction proposed originally by Skinner et al.9, adding extra 
265 
tests for executive function and verbal fluency to increase sensitivity to detect 
266 
progression from MCI to dementia. Post hoc analyses will be performed to explore the 
267 
effect of intervention on ADAS-Cog-Plus scores by adding individual Plus items, one by 
268 
one,  to ADAS-Cog-13. 
269 
10.3 Secondary Outcomes Analyses 
270 
The secondary analysis will be performed in an intention-to-treat population and a per-
271 
protocol population. The details of the statistical analysis plan for secondary outcomes 
272 
are not included in this analysis plan as the secondary outcome analyses will not be 
273 
included in this primary manuscript and performed afterwards. 
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275 
11. 
Data management and Quality Control 
276 
All sites will use the same data collection forms to maintain consistency. Data storage 
277 
and monitoring procedures will be performed using the LORIS (Longitudinal Online 
278 
Research and Imaging System) system platform for uploading data specially developed 
279 
for the SYNERGIC study by CCNA informatics team platform. Data quality will be 
280 
assessed either using Excel and the online CCNA-LORIS platform database. All data 
281 
will be entered and managed in LORIS database, and a double data entry system will 
282 
be used to assure accuracy of entry. Outliers and missing data will be managed using 
283 
statistical software adopted for the final analysis. Original completed CRFs will be 
284 
uploaded to the media module, initial and double data entries will be performed, and 
285 
arising conflicts will be resolved in the conflict resolver module. Once the conflicts are 
286 
resolved, the data will be validated by the clinical team and will be ready for release 
287 
through the data query tool. 
288 
See: https://www.frontiersin.org/articles/10.3389/fninf.2018.00085/full 
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290 
 
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SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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12. 
Programming Plans 
292 
Data analysis will be performed using statistical software SPSS (SPSS version 23.0, 
293 
SPSS Inc., Chicago, IL) and R version 3.5.1 (R Project for Statistical Computing).
294 

SYNERGIC Trial                                                                                                       Statistical Analyses Plan  
 
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References 
295 
 
296 
1. 
Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale, N.J.: L. 
297 
Erlbaum Associates; 1988. 
298 
2. 
Montero-Odasso M, Almeida QJ, Burhan AM, et al. SYNERGIC TRIAL (SYNchronizing 
299 
Exercises, Remedies in Gait and Cognition) a multi-Centre randomized controlled double 
300 
blind trial to improve gait and cognition in mild cognitive impairment. BMC Geriatr. 
301 
2018;18(1):93. 
302 
3. 
Skinner J, Carvalho JO, Potter GG, et al. The Alzheimer's Disease Assessment Scale-
303 
Cognitive-Plus (ADAS-Cog-Plus): an expansion of the ADAS-Cog to improve 
304 
responsiveness in MCI. Brain Imaging Behav. 2012;6(4):489-501. 
305 
4. 
Crane PK, Carle A, Gibbons LE, et al. Development and assessment of a composite score 
306 
for memory in the Alzheimer's Disease Neuroimaging Initiative (ADNI). Brain Imaging Behav. 
307 
2012;6(4):502-516. 
308 
5. 
McAlister FA, Straus SE, Sackett DL, Altman DG. Analysis and reporting of factorial trials: a 
309 
systematic review. JAMA. 2003;289(19):2545-2553. 
310 
6. 
Mallinckrodt CH, Lane PW, Schnell D, Peng Y, Mancuso J. Recommendations for the 
311 
primary analysis of continuous endpoints in longitudinal clinical trials. Drug Information 
312 
Journal. 2008;42:303-319. 
313 
7. 
Juszczak E, Altman DG, Hopewell S, Schulz K. Reporting of Multi-Arm Parallel-Group 
314 
Randomized Trials: Extension of the CONSORT 2010 Statement. JAMA. 
315 
2019;321(16):1610-1620. 
316 
8. 
Chakraborty B, Collins LM, Strecher VJ, Murphy SA. Developing multicomponent 
317 
interventions using fractional factorial designs. Stat Med. 2009;28(21):2687-2708. 
318 
9. 
Skinner J, Carvalho JO, Potter GG, et al. The Alzheimer's Disease Assessment Scale-
319 
Cognitive-Plus (ADAS-Cog-Plus): an expansion of the ADAS-Cog to improve 
320 
responsiveness in MCI. Brain Imaging Behav. 2012;6(4):489-501. 
321 
 
322 

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SYNERGIC TRIAL 
Protocol 201619 
11 June 2018 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 201619 
 
Proposed Changes 
Rationale 
Imaging  
Spectroscopy  
The rationale for spectroscopy is related that we have previously 
found that NAA/Cr levels in the motor cortex are associated with 
vitamin D status (Annweiler et. al. Vitamin D and Caudal Primary 
Motor Cortex: A Magnetic Resonance Spectroscopy Study, Plos 
One, 9: e87314, 2014) in MCI.  In addition, we have shown that  
NAA/Cr levels in the motor cortex are associated with worse 
stride time variability under dual task conditions (Annweiler et al. 
Motor Cortex and Gait in Mild Cognitive Impairment: A Magnetic 
Resonance Spectroscopy and Volumetric Imaging Study. Brain. 
136: 859-871, 2013). 
 
These studies suggest that NAA/Cr levels are associated with 
reduced vitamin D levels, and gait disturbance.  These studies 
provide the rational to examine the effect of exercise training 
and vitamin D supplementation (the focus of SYNERGIC) in a 
similar cohort on this metabolic indicator in the motor cortex.  
This metabolic measurement may be a more sensitive indicator 
than brain volumetrics and tissue microstructure (DTI) to 
exercise and vitamin D supplementation induced changes - 
although there is also evidence to support the use of these other 
measures in the current study. 
Blood work 
Blood draw added at T12 (final) study visit. 
Blood work is completed with participants currently at Baseline 
and also after intervention completes at their 6-month visit. This 
amendment proposes adding blood work to the final visit (12-
month visit) as a follow-up. This blood work will help to explore 
the role of exercise and cognitive training on biomarker levels 
and if there is any sustained effect of exercise or interventions 
on a deeper (biological) level. 
Site Recruitment 
Distribution of enrolled participants amended. 
The total enrolment will remain at 200 participants. 10 
participant spots from the Montreal site will be transferred to the 
London site (Parkwood Institute). 10 participant spots will be 
transferred from the Vancouver site and split evenly to the 
London (5) and Waterloo (5) site. This change is being 
implemented as the London and Waterloo sites since these sites 
are reaching trial milestones.   
 

SYNERGIC TRIAL 
Protocol 201619 
16 Nov 2018 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 201619 
 
Proposed Changes 
Rationale 
Blood Biomarkers 
IGF-1 to be added to blood work analysis. 
IGF-1 is a biomarker that has recently been associated with 
poor cognitive response to exercises and with pathologies that 
can affect vascular and brain health, like the metabolic 
syndrome. Adding IGF1 in this trial will help our researchers to 
determine profiles of responders to the exercise and cognitive 
training intervention, among our participants. Blood work is 
approved to be collected at baseline, T6 (post-intervention) and 
T12 (six months post-intervention). Other biomarkers and 
analysis currently examined are Vitamin D levels, Calcium, PTH, 
Lipid levels Serum High Sensitive CRP, IL-6, BDNF, and VEGF 
receptor 1. This addition will have no impact on the participants 
as blood work previously collected will be utilized and no 
additional draw will occur. 
Site Recruitment 
Distribution of enrolled participants amended. 
The total enrolment will remain at 200 participants. 5 participant 
spots from the Montreal site will be transferred to the London 
site (Parkwood Institute). 5 participant spots will be transferred 
from the Vancouver site to the London. This change is being 
implemented as the London site is reaching trial milestones.   
 

SYNERGIC TRIAL 
Protocol 201619 
19 Feb 2019 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 201619 
 
Proposed Changes 
Rationale 
Webpage Recruitment 
Addition of form for interested participants. 
 
For interested participants who visit the Gait and Brain 
webpage, a form will be available for them to complete in order 
to be contacted regarding the study and possible screening visit.  
Site Recruitment 
Distribution of enrolled participants amended. 
The total enrolment will remain at 200 participants. 5 participant 
spots from the Montreal site will be transferred to the London 
site (Parkwood Institute). This change will be implemented as 
the London site is reaching trial milestones.   
 

SYNERGIC TRIAL 
Protocol 201619 
18 Oct 2019 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 201619 
 
Proposed Changes 
Rationale 
Recruitment Materials 
Gait & Brain Lab Brochure 
For interested participants, a brochure will be available for them 
to read more about the ongoing research studies in the Gait & 
Brain Lab, including the Synergic Trial. If interested, participants 
can then contact the research coordinator. 
Protocol Document: Non-Local Site Recruitment 
Distribution of enrolled participants amended. 
The total enrolment will remain at 200 participants. 5 participant 
spots from the Montreal site will be transferred to the Wilfred 
Laurier (WLU) site. This change will be implemented as the 
WLU site is reaching trial milestones.   
 

         
  
̹

 
 
 
“Are you 60 years of age or older?  
The University of Waterloo Brain and Body Lab is hosting a                                 
clinical trial for participants who are experiencing memory problems. 
This five-month trial by the Brain and Body Lab focuses on the effects of                     
physical exercise, mental exercise and vitamin D. 
To learn more about this research study, contact Laura Middleton at the 
University of Waterloo or visit Synergic Trial dot com.  
That’s S-Y-N-E-R-G-I-C Trial dot com.” 
CLIENT: University of Waterloo 
REP: Patricia Azevedo 
LENGTH: 30 seconds 
DATE: 10/15/2019 
WRITER:  Ian Hunter 
TITLE: Trial Study 
CART#: CSO- 
RUN DATE: 10/21 – 10/27 
PROD INSTRUCTIONS: Cold voice, no music. MP3 to Patricia. 

SYNERGIC TRIAL 
REB# 107670 
7 April 2020 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 107670 
 
Proposed Changes 
Rationale 
Changes to study procedures, design 
Home-Based Program 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Changes to participant tools/study instruments 
Addition of new study data collection tools/forms 
 
 
 
 
 
Addition of new tools/forms to be provided to participants 
 
 
 
 
 
 
 
 
 
 
 
In line with global efforts to mitigate the spread of the COVID-19 
pandemic, we have temporarily suspended the SYNERGIC 
Trial. This decision has been made with careful consideration for 
the well-being of our participants who are classified as the high-
risk population, and the inability to deliver safe exercise to this 
population while maintaining physical distance measures. In line 
with this decision, all interventional sites began limiting access 
from an institutional-level. 
Due to institutional closures, in-gym exercise sessions are no 
longer possible. For participants who had not yet completed 
80% of interventional sessions (therefore no T6 could be done), 
they will be offered a take-home maintenance program. This 
applies to 1 participant at University of Waterloo site. This 
program will provide continuation of cognitive and exercise 
training, and vitamin D supplementation until the 20 weeks of 
intervention has been reached or until institutional closures 
cease. To maintain participant supervision in the study, research 
staff will contact participants 3 times weekly on days that would 
normally be interventional days. With participant consent, these 
will be a Zoom video call during intervention, where staff have 
the ability to supervise technique and provide insight into 
adaptations/progressions where applicable. If video calls are not 
available, telephone calls will be completed instead. 
 
Calls during interventional visits will follow a call script. This 
script includes data collection of vitamin D supplementation, 
cognitive training information, and exercise training information 
for each session. This will also feature any questions the 
participant may have regarding their tasks, any reported pain or 
discomfort, and any modifications suggested by the researcher. 
 
Participants will receive all necessary materials to continue 
home-based cognitive, exercise, and vitamin D intervention. 
This includes iPads, training manual, worksheets, vitamin D, and 
resistance bands where necessary (if participant does not have 
their own). Documents will be sent electronically. A drop-off will 
be arranged by the Research Coordinator with the participant for 
physical materials to ensure quick and sanitary delivery. Proper 
sanitization of materials will be conducted by the RC prior to 
packaging in a box and hand hygiene will be adhered to when 
delivering. This box will then be delivered to an agreed upon 
location with proper physical distancing. 

SYNERGIC TRIAL 
REB# 107670 
7 April 2020 
 
2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Changes to how data is collected/accessed 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Training manual and worksheets will be specific to 
randomization arm. Arms 1 & 2 will receive a training manual 
featuring exercises that can be done at home with minimal/no 
equipment which target the same muscle groups as the gym-
based intervention. These exercises have 3 options for 
progression. Starting level and progressions for each participant 
will be made by the researcher supervising via Zoom using input 
from the participant and observations. This training manual also 
features all warm-up and cool-down exercises, and information 
on cardiovascular exercises that can be completed at home. 
This training manual will also have information on how to access 
Neuropeak cognitive training at home. The training manual for 
arms 3-4 will be the same as that for arms 1-2, with the 
exception of the cognitive training section. This section will 
instead feature information on how to complete the control 
cognitive tasks at home. The worksheets participants would 
normally receive for cognitive control training will be provided, as 
well as the lists of places and informational videos (with links) 
that they have not yet completed during intervention. The 
training manual for arm 5 will feature the same cognitive training 
section as arms 3-4, and warm-up and cool-down stretches will 
remain consistent across all groups. Arm 5’s exercise training 
will feature light balance and toning (BAT) exercises they can 
complete at home. Participants will receive a training worksheet 
specific to their grouping, on which they can log vitamin D 
intake, cognitive training, and exercise training for the day, and 
note any questions they want to ask the research staff or 
reminders for themselves. 
 
Intervention information will be collected via Zoom video call 
during intervention and recorded on the concurrent call 
script/sheet. Storage of information will not change. The 
participants will also record their intervention information. 
 
Should the participants reach the end of their interventional 
sessions (20 weeks total) prior to reversal of institutional 
closures, the 6-month assessment will be collected via Zoom to 
avoid loss of participant data. The assessment will be 
abbreviated as gait, balance, blood work, and MRI will not be 
collected, however all cognitive testing and questionnaires will 
be collected as usual. No new assessment materials will be 
used. The assessor will indicate all responses possible on hard-
copy versions (the storage of which will not change). For 
assessments that require a paper-based copy for participant 
use, the required response sheets will be sent electronically to 
participants to be printed ahead of time (without instructions so 
as to not allow training). During the assessment, the participant 
will be asked to point the camera towards their response sheet 

SYNERGIC TRIAL 
REB# 107670 
7 April 2020 
 
3 
 
 
 
 
 
 
 
 
 
 
Changes to the Letter of Information/Consent 
 
 
 
 
 
 
 
 
 
 
 
 
and a screenshot of the response sheet will be taken by the 
researcher. The participant will not be in this frame. Screenshots 
will be saved in a secure drive. Following assessments, these 
screenshots will be printed and included in the participant's 
study folder. Any identifiable information within the screenshot 
will be removed accordingly. All cognitive tests will be done via 
Zoom, however participants will have the choice to complete 
questionnaires in a separate telephone call. 
 
LOIC addendum document will be presented to participants 
currently in intervention to gain consent for participation in 
home-based program, regular video call supervision, and 6-
month post-intervention video call assessment. LOIC addendum 
will be sent electronically to participants in intervention, reviewed 
using a telephone call with Research Coordinator, signed by 
participant if consenting, and a scanned copy will be sent back 
to the Research Coordinator. As these updates apply only to 
those currently in intervention, the updated LOIC will not be 
presented to past participants or participants who are currently 
in the follow-up period at this time. 
 
 

SYNERGIC TRIAL 
REB# 107670 
8 June 2020 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 107670 
 
Proposed Changes 
Rationale 
Changes to study procedures, design (Visit 4) 
 
 
 
 
 
 
Due to gradual opening of institutions and the staggered nature 
of these openings between London and Waterloo, the T12 
assessment will be offered in the currently approved format 
(virtual) and the previously approved format (in-person). In-
person assessments will be done when possible, but virtual 
formats will continue to be implemented a) at sites that have not 
yet opened for in-person appointments, and b) in the case 
where participants do not yet feel comfortable returning to the 
lab.  
 

SYNERGIC TRIAL 
REB# 107670 
13 May 2020 
 
1 
 
Summary of Changes Document 
SYNERGIC Trial # 107670 
 
Proposed Changes 
Rationale 
Changes to study procedures, design (Visit 4) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Changes to the Letter of Information/Consent 
 
 
 
 
 
 
 
 
 
 
 
 
Due to continuing restrictions regarding in-person research, 
participants who are due for a T12 assessment prior to the 
return to normal operations will be invited to complete a 12-
month assessment over Zoom. The assessment will mimic the 
current virtual T6 assessment occurring for this study, and will 
be abbreviated as gait, balance, blood work, and MRI will not be 
collected, however all cognitive testing and questionnaires will 
be collected as usual. No new assessment materials will be 
used. The assessor will indicate all responses possible on hard-
copy versions (the storage of which will not change). For 
assessments that require a paper-based copy for participant 
use, the required response sheets will be sent electronically to 
participants to be printed ahead of time (without instructions so 
as to not allow training). During the assessment, the participant 
will be asked to point the camera towards their response sheet 
and a screenshot of the response sheet will be taken by the 
researcher. The participant will not be in this frame. Screenshots 
will be saved in a secure drive. Following assessments, these 
screenshots will be printed and included in the participant's 
study folder. Any identifiable information within the screenshot 
will be removed accordingly. All cognitive tests will be done via 
Zoom, however participants will have the choice to complete 
questionnaires in a separate telephone call. 
 
LOIC addendum document will be presented to participants 
currently in post-intervention follow up period to gain consent for 
participation in 12-month video call assessment. LOIC 
addendum will be sent electronically to participants in 
intervention, reviewed using a telephone call with Research 
Coordinator, signed by participant if consenting, and a scanned 
copy will be sent back to the Research Coordinator. As these 
updates apply only to those currently in post-intervention follow 
up period, the updated LOIC will not be presented to past 
participants.