Rhythm Experience and Africana Culture Trial II
Phase: NA
Conditions: Cognitive Performance, Brain Structure
Sponsor: University of Pittsburgh

 
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Rhythm Experience and Africana Culture Trial 
(REACT)  
NCT Number: NCT03771716  
 
 
Approved Protocol 
 
Last Updated: August 29th, 2023 
 
 
 

 
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1.0 
SUMMARY: 
 
African Americans are almost two times more likely than whites (i.e., Caucasians) to 
experience Alzheimer’s disease or other forms of dementia (1). Higher prevalence 
translates to 45% higher Medicare costs for African Americans compared to whites (2). A 
critical public health question emerges from these statistics that we intend to address in this 
study: Is there an effective method for reducing or eliminating the race disparities in 
cognitive and brain health?  
 
Fortunately, physical activity (PA) interventions may be effective at improving 
neurocognitive function and reducing risk for dementia. Despite these promising results, 
prior PA interventions have had few African Americans making it difficult to stratify 
results by race to determine whether African Americans respond to PA in a similar manner 
and magnitude as whites. In addition, the terms ‘physical activity’ and ‘exercise’ are often 
considered unpleasant, painful, and fatiguing, which can negatively influence interest, 
enrollment, and long-term adherence to PA interventions. 
 
Here, we propose an innovative and culturally sensitive method of increasing PA in older 
(60-80 yrs.) African Americans. We will conduct a randomized intervention where 180 
older African Americans are assigned to either a moderate intensity African Dance group 
3 days per week (N=90) or to an Africana Culture group 3 days per week (N=90) for 6-
months. Both before and at the completion of the intervention, we will collect a 
comprehensive neuropsychological battery, physiological health metrics, and MRI metrics 
of brain health and function to identify biological pathways by which PA influences 
neurocognitive health in an African American population. 
 
We have assembled a highly creative, productive, and interdisciplinary team with a long 
history of collaboration and experience conducting exercise interventions in older adults 
to test the following aims:  
Aim 1. Examine whether a 6-month African Dance intervention improves cognitive 
performance compared to the culture control group. H1: The dance group will show 
cognitive improvements in a domain-specific fashion such that executive and memory 
functions will be enhanced more than other cognitive domains. 
Aim 2. Examine whether African Dance influences brain morphology, task-evoked neural 
responses, cerebral blood flow, and resting state connectivity. H1: We predict that African 
Dance will increase volume, white matter integrity, perfusion, and functional 
activation/connectivity in a regionally-specific fashion such that prefrontal and 
hippocampal areas will be more sensitive to the intervention than other brain regions.  
Aim 3. Explore potential physiological and socioemotional mechanisms of the dance 
intervention. We will collect measures of physical and psychosocial health such as waist 
circumference, blood pressure, blood glucose and lipid levels, mood, anxiety, depression, 
and loneliness and examine whether intervention-related changes to these measures 
mediate improvements in cognitive performance.  
 
 

 
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1.1 
BACKGROUND AND RATIONALE: 
 
1.1.1 Health Disparities and Age-Related Neurocognitive Decline.   
When compared to whites, African Americans are 2-3 times more likely to develop 
dementia (1, 3). Such striking health disparities do not appear to be driven by genetic 
factors but by increased rates of vascular diseases, obesity, and hypertension in African 
Americans (4–6). Despite such remarkable disparities, African Americans are 
routinely underrepresented in both longitudinal studies and clinically randomized 
trials for prevention or treatment of cognitive decline.  
 
Cognitive performance typically declines across the adult lifespan with executive and 
inhibitory control processes, working memory, and episodic memory displaying early 
and disproportionate decline (7). Brain atrophy precedes cognitive decline in a graded 
fashion with prefrontal and medial temporal lobes showing earlier and more rapid 
decline (8–10). Although the biological bases for these changes remain unclear, 
cardiometabolic risk factors predict and possibly contribute to accelerated loss (11, 12). 
For example, our group demonstrated that obesity is associated with diffuse reductions 
in white matter integrity (13).  
 
Increased prevalence of vascular and metabolic risk factors in African  
Americans is thought to contribute to their increased risk for neurocognitive  
deficits (4, 5, 14). For example, 72% of African Americans over the age of 55 have 
high blood pressure compared to 54.0% of whites (15) and, after adjusting for age, 
46.55% of African Americans meet criteria for obesity compared to 33.8% of whites 
(16). Because of elevated vascular risks in African Americans, decline in brain integrity 
and function may occur earlier in the lifespan than for  
whites (10, 12, 17). As such, interventions that target cardiovascular health in  
African Americans could have significant consequences on neurocognitive  
function.  
 
1.1.2 Physical Activity (PA) Restores Brain Function. PA has emerged as a 
promising, low-cost method for improving neurocognitive function in older adults (18–
21). Prospective epidemiological studies indicate that physical inactivity is a significant 
risk factor for dementia and potentially contributes to 21% (over 1.1 million) of AD 
cases in the US (22). Randomized interventions have shown restorative effects of PA 
on cognitive and brain outcomes in older adults (18, 20). For example, moderate 
intensity exercise, in the form of brisk walking, improves cognitive function in as little 
as 3-months, primarily in domains of executive function and memory (23). In addition, 
our research group has found that higher fit adults have larger hippocampal volumes 
than less fit counterparts (24) and that a one-year walking intervention reverses age-
related atrophy of the hippocampus (18). Our research has also found that walking 
about 1 mile per day was sufficient to spare gray matter volume in prefrontal and 
hippocampal areas and that greater volume in these regions cut the risk of cognitive 
impairment in half (25). These changes have downstream effects on brain function. For 
example, we have demonstrated increased activity in prefrontal and parietal regions 
during inhibitory control after 6-months of exercise training (26). Furthermore, we 

 
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found that exercise training increased functional brain connectivity between the 
posterior cingulate and hippocampal and frontal medial cortices relative to the control 
group (27).  
 
There are three important take-home messages from this research: 1.) Diminution: a 
sedentary lifestyle leads to cognitive and brain decline, 2.) Plasticity: the brain remains 
modifiable throughout the lifespan and PA has the capacity to take advantage of this 
property, 3.) Intervention: PA interventions enhance brain integrity. Despite these well-
established principles, evidence for all of them comes from studies with predominantly 
Caucasian participants, even though African Americans could equally gain from such 
an intervention.  
 
1.1.3 Dancing as a method for increasing PA.  Dancing is an engaging form of PA 
that attracts cross-generational groups of all races and ethnicities. In particular, older 
adults prefer activities involving music, which is why dance is often used in senior 
centers and nursing homes as a therapeutic tool to elevate activity (28). Randomized 
interventions have demonstrated that dancing is effective at increasing PA and 
improving physical fitness. For example, traditional ballroom, tango, or salsa, improves 
mobility, balance, motor skills and coordination, and resting heart rate in older adults 
(29, 30). Dancing also improves self-confidence, motor skills, mood (31) and cognitive 
function (e.g., 32) while epidemiological studies find that dancing reduces risk for 
cognitive impairment (33). Preliminary data from our lab suggests that dancing also 
improves balance, gait, and cognitive function (34). 
 
African Dance refers to a loose constellation of dance practices derived from Africa. In 
part because of the large African diasporic population in the US, African Dance is 
surging in popularity in many cities and has helped revitalize the roots and traditions 
of African culture by educating both the black and white communities in African 
heritage. African dance differs from almost all other dance cultures in one primary way. 
Whereas in the majority of dancing around the world the body is treated as a single 
“block,” in African dance the body has multiple, semi-independent centers (35). In 
African dance, the torso, shoulders, pelvis, and legs are relatively independent – each 
region of the body follows a different rhythm and gestural pattern. Because of African 
dance’s “polycentricity” (35), total body articulation is heightened and therefore 
requires significant movement, coordination, and endurance. Hence, African Dance is 
engaging while also being a moderately intense form of PA. In sum, African Dance is 
an effective and engaging method of increasing PA and is culturally sensitive and 
appealing to an African American community (see below for preliminary data). 
 
1.1.4 Innovation 
Our primary goal is to conduct a study that will transform scientific-based policy and 
health care recommendations for improving cognitive function and reducing health 
disparities in older African Americans. We have assembled a highly productive and 
interdisciplinary team with a long history of conducting this type of research to provide 
answers to important unsettled scientific questions that have critical public health 

 
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consequences. Ours will be the first study of its kind, is highly innovative, and will add 
to the scientific literature in several important ways:  
 
(1) For the first time, we will examine whether systematically increasing PA through a 
randomized African Dance intervention enhances neurocognitive function in African 
Americans. Our research group has demonstrated the benefits of PA on brain and 
cognition (13, 18, 24, 25, 27, 36–38), but these studies have almost exclusively studied 
majority Caucasian samples. Hence, there is an immediate need to expand these results 
to minority, and more vulnerable, populations.  
(2) We will examine whether African Dance is effective at improving brain morphology 
and function using cutting-edge MRI sequences and analytical approaches. Our group 
has previously described the effects of PA on brain morphology and function (18, 20, 
27), but these studies have had only small numbers of African Americans.  
(3) For the first time we will examine whether increasing PA through African Dance 
could serve as a platform to assess health disparities. As such, our innovative design 
could be molded into future interventions targeting other biological systems and to 
assess reductions in health disparities.   
(4) By taking advantage of a culturally sensitive activity we will be able to target a 
minority population that has traditionally been underrepresented in clinically 
randomized trials of brain health.  
 
1.2 
PRELIMINARY DATA: 
 
We describe three areas of preliminary data that demonstrate effects of exercise on 
cognitive and brain outcomes including results from our pilot African Dance study that 
formed the basis for this trial.  
 
1.2.1 Effects of exercise on cognitive function: Our group was one of the first to 
demonstrate the favorable effects of a 6-month aerobic exercise RCT on cognitive 
outcomes (39, 10). In a meta-analysis of 18 RCTs in older adults, we found that 
exercise broadly influenced cognitive function (Hedge’s g=.47), but improved 
executive function more than other cognitive domains (Hedge’s g=.67), with the 
largest effect sizes for study durations of 6 months or longer (23). These 
encouraging effects have now been replicated by our group and others (18, 27, 40). 
Implications: We have significant experience conducting PA interventions. Our 
results demonstrate that >6-months of PA improves cognitive function and that we 
have been successful at recruiting and retaining older adults in PA intervention 
trials.   
 
1.2.2 Effects of exercise on brain outcomes: Our research group has published 
>100 papers on the effects of exercise and fitness on brain morphology, white 
matter integrity, resting state connectivity, and task-evoked functional MRI 
activity. In 120 cognitively normal adults between 60-80 yrs of age (N=60/group), 
moderate intensity exercise was effective at increasing hippocampal volume, which 
was correlated with improvements in spatial memory (18). In addition to brain 

 
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morphology, changes in cardiorespiratory fitness resulting from an exercise RCT 
were correlated with increased white matter integrity in PFC and temporal lobes in 
70 cognitively normal adults (41). Our results also extend to resting-state 
connectivity and task-evoked activation. For example, in 65 cognitively normal 
older adults exercise increased functional connectivity (27) and these changes were 
correlated with improvements in executive function, memory, and increases in 
serum BDNF and IGF-1 (37). Implications for this project: Our team is well-versed 
in the methods, challenges, and analytical approaches for examining MRI outcomes 
in PA interventions. We have been successful in coordinating neuroimaging efforts 
across sites and maintaining participants in MRI studies that are >1 year in duration.  
 
1.2.3 Results from a pilot African Dance intervention. We have preliminary data 
from a pilot sample of 33 older African Americans tested across 2 study waves with 
an average age of 69.21 (standard deviation = 3.60). One-third of the sample 
reported a family history of cognitive impairment. The data from this study was 
collected as part of an Alzheimer’s Association-funded study on non-
pharmaceutical interventions to reduce disparities in cognitive decline (PI: 
Erickson; NPSASA-14-321093). 
We randomized participants into one of two groups – an African Dance group 
or an Africana Education control group.  Participants in both groups completed 
three 1-hour sessions per week for 6 months. Participants (N=19) in the Dance 
group learned traditional dances from Guinea and South Africa. The dance class 
started with ~5 minutes of warm-up and dynamic stretching followed by ~50 
minutes of instructor-led dance sequences while continuously moving, and finally 
~5 minutes of cool down and static stretching. Resting blood pressure and resting 
heart rate measurements were taken at the beginning and end of class. Heart rate 
was monitored continuously throughout the class and recorded every 15 minutes. 
Rating of Perceived Exertion (RPE) from each participant was also recorded at the 
end of each class. A trained staff member monitored participants’ heart rates to 
ensure participants remained in the target heart rate zone (60-75% of their age-
predicted maximal heart rate (APMHR)) for the duraton of the class. 
Participants in the Education class (N=14) learned about Africana History in 3 
sections organized by time period: pre-colonial, colonial, and post-colonial. The 
topics covered in each section included culture/way of life/customs, spirituality, 
ethnicity, language, family structures, rites of passage, political structures, and 
economy. The format of the class was discussion-based and was led by staff 
originating from Africa. For each topic, instructors typically lecture or show an 
educational film for part of the hour. The remaining class time is spent in an 
instructor-led discussion.  
Sixty-six African American older adults (53 female; Mean age = 69.4 + 4.9 
years) were screened and scheduled for baseline testing in Pittsburgh. Of this group, 
48 (~90%) successfully completed the baseline measurements and were 
subsequently randomized and enrolled. First, we successfully maintained heart rate 
in our prescribed heart rate zone. On average, participants in the Dance group 
maintained a heart rate (HR) of 68.3% of their APMHR throughout the intervention 
classes. Thus, our dance intervention was effective at maintaining a HR intensity 

 
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in the target range and can be considered a form of moderate-intensity PA. Second, 
enrollment and adherence continued to improve with each wave of the intervention 
so that attendance rates in the last wave were >70% for both groups. Attendence 
rates improved from the first to the second cohort, and enrollment rose from 7 
participants in the Dance group and 3 in the Education group in wave 1, to 12 and 
11 participants in these two groups, respectively, in wave 2. Importantly, we 
learned successful advertising methods and tactics to improve attendance. We plan 
to implement several strategies to further promote attendance in the present study 
(e.g., transportation support, raffles, performance summaries). We found that 
participants were overwhelmingly enthusiastic about both interventions. On 
average, participants rated the enjoyability of the Dance and Education 
interventions as 5.0 and 4.6, respectively, on a scale of 1-5. In fact, when asked 
what they would improve about the intervention, many participants suggested that 
we make the intervention duration longer. 
 
1.3  
STATISTICAL ANALYSIS: 
 
 
1.3.1 General Approach. We will analyze data in an intent-to-treat (ITT) manner such 
that all participants, regardless of whether they complete the intervention, will be 
invited to return for the follow-up sessions and will be included in primary analyses. 
Secondary analyses will be conducted using a per-protocol approach, which restricts 
the analysis to the participants that completed the intervention. All cognitive and 
neuroimaging data will be interrogated for normality, and symmetry, and any non-
normal data may be transformed based on the distribution of error terms. Any data that 
cannot be transformed will be analyzed using non-parametric tests. Non-parametric 
regression models will be used for continuous variables when necessary. We will 
examine the data for potential outliers.  If it is determined that outliers are due to 
misreporting of data or administrative error, we will delete them from the analysis. If 
the outliers are not due to misreporting of data or adminstirative error we will conduct 
the analysis with and without outliners included.  Outlier de-weighting will be 
conducted on voxel-wise MRI data to remove the influence of anomalous voxels in the 
analysis. All analyses will be two-tailed. We will first summarize baseline demographic 
and brain characteristics of the sample and intervention groups using descriptive 
statistics and statistical hypothesis testing.  Descriptive statistics will include mean, 
median, standard deviation, range for continuous variables, and frequency for 
categorical variables.  Statistical tests will be conducted using t-test, ANOVA F-test, 
Chi-square test, correlations (Pearson or Spearman) as appropriate. Our primary goals 
are to examine whether the intervention improves cognitive and brain health. To test 
these hypotheses, we propose to use a General Linear Mixed Model (GLMM) in 
standard neuroimaging and statistical packages. Effects of Time (baseline, 6-month), 
Group (Dance, Education), and Time by Group interactions will be examined. Post-
hoc comparisons using least square means will decompose any significant interactions 
and will be plotted to illustrate the direction of the effect. Mean differences between 
groups for all cognitive and neuroimaging outcome measures will be derived using 
linear contrasts and multiple comparisons will be corrected by standard protocols. 
Differences in baseline characteristics will be accounted for by using covariance 

 
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adjusted models We will conduct multiple sensitivity analyses to examine and 
determine how to handle missing data. Based on a Missing at Random assumption, the 
distributions of the missing data will be examined and will be compared. The potential 
effect of missing data on the primary hypothesis tests will be adjusted by including 
covariates that are significantly associated with missing data in the regression models.  
We will describe differences in baseline characteristics between participants with 
complete versus incomplete follow-up to assess any bias (e.g., age) in those who do not 
return for follow-up. However, according to ITT analyses, all participants including 
those that do not complete the intervention will be analyzed as part of the trial. Using 
hierarchical regression models, we will be able to explore whether changes in any 
cognitive or neuroimaging metric (e.g., white matter integrity) varies as a function of 
improvements in PA or fitness independently of assigned group. We also appreciate 
that there will be significant individual variability in factors such as body mass, blood 
pressure, fitness level, or SES. Instead of modeling this variation as ‘noise’ we plan to 
take advantage of the variability to further explore, independently of group assignment, 
the associations between cognitive and brain imaging metrics and initial levels and 
individual change trajectories. Main effects and interaction terms will be modeled in 
these regression analyses and time-dependent changes will be explored and illustrated 
by scatter and spaghetti plots. These analyses will be useful for generating future 
hypotheses and questions. 
Aim 3 proposes to explore physiological and socioemotional mechanisms of the 
dance intervention. We plan to explore our hypotheses using several different 
approaches including simple mediational models applying the change score method 
and will estimate whether the dance intervention (predictor) on changes in cognitive 
function outcomes are mediated through changes in the suspected mediators. 
Goodness-of-fit will be assessed through standard summary indices (e.g., RMSEA, 
CFI) and model assessment via residual analyses will performed. Total, indirect and 
direct effects will be estimated. Additionally, we will explore mediation applying the 
half-longitudinal approach proposed by Cole and Maxwell as well as an autoregressive 
mediational approach. Finally, we will explore recent advancements in repeated 
measures mediation analyses developed by Preacher and Hayes. Depending on the 
results from simple mediational modeling, we may also combine mediators into a 
multiple mediator model to develop a more comprehensive picture of these pathways.  
 
1.3.2 Power Analyses.  Our planned sample size of 180, with randomization of 90 
participants in each group, is based on effect sizes from preliminary data. Even when 
accounting for attrition and retention of ~70% of participants (65 in each group), we 
are sufficiently powered to detect effects in cognitive and brain outcomes and to test 
for mediation. 
 
1.3.3 Cognitive performance. Our prior PA interventions have found moderate sized 
effects on cognitive function after 6-months with a Cohen’s d ranging from 0.40 to 0.80 
depending on the outcome (23). In our analysis of the pilot data from the African Dance 
intervention with only 19 participants (9 in the Dance group) we estimate similar or 
greater effect sizes of ~.70. If we estimate an effect of 0.70, 65 participants per group 
after attrition will provide us with >91% power to examine our primary hypotheses. 

 
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1.3.4 Brain Volumetrics. Our prior 6-12 month PA interventions have used between 
30 and 60 subjects per group with Cohen’s d ranging between 0.40 and 0.50 using 
similar analysis approaches (18, 20, 27, 41, 42). Cross-sectional research has reported 
significant effects of PA on brain volume with as few as 32 subjects and effect sizes 
between 0.50 – 0.60 (24, 40, 42–44). Preliminary data on 37 African Americans from 
one of our prior studies suggest that cross-sectional differences between African 
Americans engaging in PA compared to those not engaging in PA are larger than for 
whites (Cohen’s d = 1.83). These studies argue for a moderate-to-large effect of PA on 
brain volume depending on the sample, the measure of PA and fitness, and the brain 
metric used. If we estimate a conservative effect size of 0.50, 65 participants per group 
will be sufficient to detect differences in brain volume at 81% power.  
 
1.3.5 Diffusion tensor imaging. Changes in white matter have been detected in PA 
interventions in as little as 6-months with only 50 subjects (45). In a 12-month PA 
intervention, we found increased FA with only 35 subjects in each group with an 
estimated effect size of 0.70 (41). Based on an estimated effect size of 0.75, we should 
have >85% power with 65 participants per group to test our main hypotheses as well 
as enough power for exploratory analyses.  
 
1.3.6 Task-evoked activity. Task-evoked brain imaging studies of PA have found 
statistically significant effects with 30 - 50 subjects per group with effect sizes ranging 
between 1.0 and 1.3 depending on the region examined and the task employed (26). 
Cross-sectional studies of fitness on brain activity report even larger effects up to 1.70 
(36, 46, 47). These patterns indicate a large effect size of PA on brain function, so 65 
participants per group will provide us with substantial power to test our main aims and 
hypotheses. 
 
1.3.7 Connectivity. With only 65 people, we have shown that a PA intervention is 
effective at enhancing functional connectivity in prefrontal-inhibitory networks (27). 
The difference between the groups for prefrontal cortex connectivity was .15 with a 
standard deviation of .10 suggesting an effect size of 1.5 (Cohen’s d). Therefore, similar 
to the effect sizes and power for the other measures, 65 participants per group should 
be sufficient for detecting changes as a function of the intervention with >85% power.  
 
1.7 
PROCEDURES: 
 
Before the collection of baseline data, all staff will have had ethics training and 
appropriate certification of research training modules.  All staff will also be a part of a 
training certification to ensure that all data collection practices will be conducted in the 
same way by all study staff.   
 
1.7.1  Phone Screening 
During the phone screen, numerous medical history questions will be asked to 
verify that the subject meets inclusion criteria (see Chapter 2):  Inclusion and 
Exclusion and below for more details). Medical record retrieval will not be used, 

 
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nor will be PCP approval be required for participation unless the study staff 
identifies a potential medical issue that warrants such approval (e.g., a previous 
cardiac event).  Information about safety to exercise will be obtained over the 
phone (e.g., history of falls).  Finally, information regarding metal in the body and 
history of claustrophobia for MRI safety will be obtained including information 
about any metallic objects in their body and claustrophobia.   
 
1.7.2 Inclusion and Exclusion Criteria. 
Inclusion Criteria:  
•     African American men and women (race self-identified) 
• 
Between 60-80 years of age at enrollment 
• 
Ambulatory without pain or the assistance of walking devices  
• 
No history of falls or balance problems  
• 
Able to speak and read English  
• 
Available during the times that classes are offered, and able to make at 
least 80% of offered classes (e.g., no long-term travel plans) 
• 
Reliable means of transportation or willingness to let us develop a 
transportation plan for them 
• 
Willingness to be randomized to either group 
• 
Scores on the TICS or MOCA that indicate no more than mild 
cognitive impairment (scores 26 or above or 21 and above, 
respectively) 
• 
No diagnosis of a neurological disease that primarily affects central 
nervous system function (e.g., dementia, multiple sclerosis, 
Parkinson’s disease).   
• 
No current diagnosis of a psychiatric condition (e.g., a current 
depression or anxiety disorder). 
• 
Eligible to undergo MRI (not claustrophobic and no metal or history of 
injury involving metal that could be a safety concern for the MRI) 
• 
Able to complete a submaximal fitness test 
 
Exclusion Criteria:  
•     Not self-identified as African American 
• 
Not between the ages of 60 and 80 at the time of enrollment 
• 
Not fluent in English 
• 
Not available for at least 80% of times classes are offered 
• 
Not willing to be randomized into either group 
• 
Does not have reliable means of transportation and not open to us 
assisting them with a transportation plan 
• 
Scores below 26 on the TICS, or below 21 on the MOCA (indicating 
moderate or severe cognitive impairment) 
• 
Metal in body or history of injury involving metal that isn’t approved 
by an MRI safety committee 
• 
Claustrophobia 
• 
History of severe head trauma, major stroke, or brain tumors 

 
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• 
History of psychiatric disorders other than past major depressive 
episodes or anxiety 
• 
History of falls or other balance problems 
• 
History of heart or cardiovascular disease, including heart failure, 
angina, or hypertension not currently controlled by medication (i.e., 
exceeding 190/100). 
• 
Unable to complete submaximal fitness test 
 
1.7.3 Baseline Testing.  
There are several outcome measurement sessions at baseline (Cognitive, 
Fitness/Blood, and MRI sessions) which must be completed prior to 
randomization.  It will be recommended that all assessments happen within a 6-
week window that starts the day the informed consent document is signed at 
session 1.  However, given challenges with scheduling and safety clearances that 
may be necessary in older adults, we will work to collect all baseline data on 
participants, even if the session exceeds the 6-week window.  
 
Session 1:  Participants will come to the laboratory and complete a battery of 
cognitive and neuropsychological tests (see below for a description of the tests).  
Compliance with the test instructions will be monitored by a study certified 
administrator. Participants will be allowed to take breaks between tests on a 
regular basis to help reduce fatigue. The cognitive tasks to be completed during 
the cognitive session are described in more detail below. The tasks can be 
grouped into several broad cognitive categories: 
 
• 
General Cognition: 
1. MOCA (Montreal Cognitive Assessment): 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.  
2. Wechsler Test of Adult Reading (WTAR): estimates pre-morbid 
intellectual functioning (approximate intelligence).  This test takes 
approximately 5 minutes to administer and will only be administered 
at the baseline testing session. 
 
• 
Working Memory: 
1. Spatial Working Memory (SWM): measures spatial memory functions 
and takes about 10 minutes.  It requires that subjects attend to and 
retain the location of several dots presented simultaneously on a 
computer display.  They are requested to press buttons on a keyboard 
that correspond to whether a probe dot appeared in one of the same 
locations as the previous dots. 

 
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2. List Sort Working Memory: (10 minutes) This task is from the NIH 
Toolbox and assesses working memory and requires the participant to 
recall and sequence different visually and orally presented stimuli. 
Pictures of different foods and animals are displayed with both an 
accompanying audio recording and written text that names the item. 
The participant is asked to repeat the items back to the examiner in 
size ordered from smallest to largest.  
 
• 
Executive Function:  
1. Trail Making B (5 min): This task measures executive control (part B). 
Both parts of this test consist of 25 circles distributed over a sheet of 
paper. In Part A, the circles are numbered 1-25, and the subject is 
instructed to draw lines to connect the numbers in ascending order. In 
Part B, the circles include both numbers (1-13) and letters (A-L); as in 
Part A, the patient draws lines to connect the circles in an ascending 
pattern, but with the added task of alternating between the numbers 
and letters (i.e., 1-A-2-B-3-C, etc.). The task is discontinued if the 
subject has not completed both parts after five minutes have elapsed.  
2. Dimensional Card Sort: (6 minutes) This task is part of the NIH 
Toolbox and measures cognitive flexibility and attention. Two target 
pictures are presented that vary along two dimensions (e.g. shape and 
color). Participants are asked to match a series of bivalent test pictures 
(e.g., yellow balls and blue trucks) to the target pictures, first 
according to one dimension (e.g., color) and then, after a number of 
trials, according to the other dimension (e.g., shape). The relevant 
dimension for sorting is indicated by a cue word (e.g., “shape” or 
“color”) that appears on the screen for all participants. 
3. Flanker: (4 minutes) This is a measure of inhibitory control and 
attention and is part of the NIH Toolbox. The task requires the 
participant to focus on a particular stimulus while inhibiting attention 
to the flanking stimuli.  
4. Color-Word Stroop (10 minutes): The Stroop Task measures selective 
attention, cognitive flexibility and processing speed.  This task is 
administered on a computer and the participants are asked to respond 
to the colors of the ink of printed words on the display as quickly as 
they can while ignoring the meaning of the word.  The task takes less 
than 10 minutes to complete.   
 
• 
Processing Speed: 
1. Trail Making A (5 min; see description of Trails Part B above): This 
task measures processing speed (part A). As with Part B, the test 
consists of 25 circles distributed over a sheet of paper. In Part A, the 
circles are numbered 1-25, and the subject is instructed to draw lines to 
connect the numbers in ascending order. The task is discontinued if the 
subject has not completed both parts after five minutes have elapsed.  

 
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2. Digit Symbol Substitution Test Coding (3 min; DSST): This task is 
part of the RBANS. Digit Symbol Substitution asks participants to 
match symbols with their corresponding digit. It consists of 9 digit 
symbols matched with their corresponding numerical digit and only 
takes approximately 3-4 minutes to administer. 
 
• 
Episodic Memory: 
1. Word List: This is part of RBANS.  A list of 10 semantically unrelated 
words is orally presented, and the examinee is asked to recall as many 
words as he or she can remember. This process is repeated over 4 
learning trials.  
2. Story Recall: This is part of RBANS. A short story is orally presented, 
and the examinee is asked to retell the story from memory. The same 
story is presented a second time, and the examinee is again asked to 
retell the story from memory.  
3. Word List Recall: The examinee is asked to recall the list of 10 words 
learned in the List Learning subtest. 
4. List Recognition: The examinee is read 20 words (10 targets, 10 
distractors) and asked to indicate whether each word was on the word 
list. 
5. Story Memory: The examinee is asked to retell the story they learned 
earlier. 
6. Figure Recall: The examinee is asked to draw the figure shown earlier 
from memory. 
 
 
• 
Visuospatial/Constructional: 
1. Figure Recall: This is part of the RBANS. The examinee is shown a 
multipart geometric drawing and is asked to make an exact copy while 
the drawing remains on display. 
 
2. Line Orientation: The examinee is presented with the drawing that 
consists of 13 equal lines radiating out from a single point to form a 
semicircular fan-shaped pattern. All lines are numbered (1-13). Below 
this drawing are two lines that match two of the lines from the array 
above. The examinee is asked to identify which two lines they match. 
Ten trials are given, with different sets of test lines on each trial.  
 
 
• Language:  
1. Semantic Fluency test: This is a semantic fluency test that is part of the 
RBANS. In this task, the examinee is given one minute to name as 
many exemplars as possible from a given semantic category (e.g., 
Fruits and Vegetables). 

 
14
2. Picture Naming: The examinee is presented with a series of pictured 
objects and is asked to name each one. A semantic cue is provided 
only if an object is obviously misperceived.  
 
 
The following questionnaires will also be completed either during the outcome 
sessions or taken home by participants to complete.  They are administered at 
baseline and after completion of the intervention:  
 
• Demographics, Health History, and Lifestyle: 
1. Health History  
2. Demographic Questionnaire  
 
We also plan to collect a number of other questionnaires at both time points, 
including, but not necessarily limited to:  
3. MacArthur SES 
4. Positive and Negative Affect Schedule (PANAS) 
5. Satisfaction with Life Scale (SWLS)  
6. UCLA Loneliness Scale  
7. The Pittsburgh Fatigability Scale 
8. Center for Epidemiology Studies Depression Scale (CES-D) 
9. Everyday Cognition Questionnaire (ECOG) 
10. McGill Pain Questionnaire 
11. PROMIS – Physical and Mental, as well as Global Health items 
 
Session 2: The second session will consist of the fitness assessment.  
Staff will begin by obtaining a resting blood pressure and heart rate. As long as 
blood pressure and heart rate are within the permitted safety guidelines (link to 
Fitness MOP chapter), the participant will begin the Senior Fitness test (link to 
Senior Fitness test in MOP chapter). Note that the Senior Fitness Test must be 
completed prior to the submaximal exercise test in order to limit effects of fatigue 
on these measures. The participant will rest for a brief period and complete some 
brief questionnaires related to physical activity behaviors and feelings before 
moving on to the submaximal exercise test. 
 
Participants will complete a submaximal graded exercise test on a motor-driven 
treadmill to assess cardiorespiratory fitness (VO2). The participant will be fitted 
with a chest-worn Polar Heart Rate monitor and three ECG electrodes. The test 
will follow a Modified Balke Protocol in which the speed of the test will be 
mutually agreed upon by the participant and exercise physiologist. Treadmill 
speed will remain constant while grade will increase every two minutes.  
 
Before beginning the submaximal test, a second resting blood pressure will be 
obtained. Only participants with safe blood pressure readings will be allowed to 
continue.  
 

 
15
During the fitness test, the participant’s expired air will be collected while 
walking on the treadmill. The participant will wear a fitted facemask which is 
connected to a metabolic cart in order to analyze all respiratory gases. This VO2 
test usually takes about 15 - 30 minutes to complete depending on the starting 
fitness level of the participant. These procedures follow guidelines recommended 
by the American College of Sports Medicine for graded exercise testing. During 
the test, heart rate is continuously monitored via the Polar Heart Rate monitor 
chest strap. Blood pressure readings and Rating of Perceived Exertion (RPE) will 
also be recorded during every two-minute stage. When the subject reaches the 
endpoint of the exercise test (85% age-predicted maximal heart rate, RPE ≥15 for 
those prescribed beta-blockers, safety concerns, or participant request), the 
facemask will be removed and they will undergo a four-minute active cool-down 
in which they will walk at a slower rate with zero incline grade. After these four 
minutes, the participant will be helped off of the treadmill and undergo a passive 
cool-down seated in a chair. The participant's heart rate and blood pressure will be 
recorded every two minutes throughout the cool-down period. The participant will 
not be allowed to leave until vital signs return to normal patterns (systolic and 
diastolic blood pressure within 20 mmHg of resting values and heart rate within 
20 beats per minute of resting values). 
 
Each submaximal exercise test will be administered by a trained exercise 
physiologist and assistant. The assistant will record the required values of each 
stage and aid with test administration.  The assistant will be another exercise 
physiologist/technician, nurse, or staff with a medical background.  All exercise 
testing staff must complete the REACT II certification standards.  The exercise 
testing will be used to measure changes in fitness levels after the 6-month 
intervention. The testing site will have the room set at a comfortable temperature 
(60 – 70 degrees Fahrenheit), have necessary fans in place and have access to 
water for the participants. 
 
At the conclusion of the fitness visit, participants will be fitted with a 
commercially available physical activity monitoring device (i.e., Actigraph) 
around the non-dominant wrist and/or hip (as instructed by the fitness staff 
member) that will record objective physical activity data over the duration of 
approximately one week. Participants will be provided with detailed instructions 
regarding wearing of the device as well as the option to remove the device if it 
becomes problematic.  
 
Once the VO2 session and Actigraph fitting is complete, the research staff 
member will email the participant a link to complete the diet history questionnaire 
(NCI). Participants will be asked to click on the link and complete the 
questionnaire on a home computer. If the participant does not have access to a 
home computer, they will be permitted to complete this assessment on a computer 
within the lab. 
 

 
16
Session 3:  The third session will generally consist of the blood draw and an MRI 
scan (exact session content may be changed as needed – e.g., based on MRI 
availability). This session will be scheduled in the morning because the blood 
draw must be done in a fasted state. Both before randomization (at baseline) and 
after the intervention we will collect approximately 60 cc of blood for a total of 
120 cc for each subject during the duration of the study. Blood collection will be 
postponed in subjects experiencing an acute infection (e.g., respiratory or flu-like 
symptoms). Another session may be scheduled for the blood draw in the case that 
a participant forgets to fast or is experiencing acute illness. After blood is 
collected, the subject will be provided with a light snack and water or juice. They 
will also be reminded (in pre-session reminder call) to drink plenty of water 
before and up to the actual blood draw and to take medications on their normal 
schedule.  
 
Following the blood draw, practice for the MRI session will begin in the cognitive 
testing room. It is anticipated that the entire length of the MRI session (from the 
beginning of blood draw to the scan conclusion) will take about 2.5 hours. This 
includes the blood draw itself and brief snack break, transitions to and from the 
scanner, tech metal screening, practice of tasks outside scanner, and scan time. 
Participants will be scheduled well in advance for the MRI scan and standard 
sequences will be collected that will consist of images of brain structure and 
function. To assess brain function, we will use an n-back paradigm that measures 
working memory. Before entering the MRI machine, participants will undergo an 
additional safety screen by the MRI center technicians and will be instructed 
about the task and be allowed to practice the tasks that they will be performing 
along with completing any questionnaires that weren’t completed in prior 
sessions.  All data collected during this session will then be interrogated for 
quality control. 
 
During the N-Back, the subject will be presented with a sequence of stimuli, and 
the task consists of indicating when the current stimulus matches the one from n 
steps earlier in the sequence. The load factor n can be adjusted to make the task 
more or less difficult. For older adults, the maximum load is usually 2 (i.e., the 
most difficult condition asks participants to make 2-back judgments).  
 
MRI Sequences: 
• Scout 
• MPRAGE 
• Resting State fMRI 
• N-Back 
• Hippocampal subfield sequence 
• DSI (Diffusion Spectral Imaging) 
• FLAIR 
• pCASL 
 

 
17
If the research team discovers an incident or abnormality (e.g., tumor) as a part of 
the MRI scan, it is important for the study subject to be informed (a) that these 
scans were not designed for clinical purposes and so a clear diagnosis and 
prognosis cannot be made, but (b) that if an incidental finding or abnormality is 
found in the scan that we will follow standard procedures of the MRI center 
which includes the consultation of a board certified neuroradiologist at the 
University of Pittsburgh. The consultation would involve an assessment of the 
scan and the neuroradiologist would provide feedback to the Principal 
Investigator to pass along to the subject. This may require the Principal 
Investigator to recommend that the subject inform their personal physician about 
the abnormality and request follow-up procedures that are outside the purview of 
the research study. 
 
1.7.4 Post-Randomization Tasks. The self-efficacy questionnaire will be 
completed during the third week of the intervention.  In addition, the physical 
activity monitoring device will be worn for one week, every 6 weeks for the 
duration of the study.  
 
1.7.5 Follow-up Testing (6 months). After 6-months of the intervention 
sessions, the participants will complete one cognitive assessment similar to that of 
the baseline visit.  The tasks will be the same as those described above but will 
not include the WTAR or the Health History questionnaire.  This time point also 
includes a blood draw to collect the same biomarkers as the Time point 1 blood 
draw. 
 
1.7.6 Blinding of Study Staff. All study staff administering the outcomes 
assessment sessions will be blinded to participants’ group assignments. Given 
this, special planning is in place to ensure adequate staffing for both the pre- and 
post- assessments.  
 
 
 
1.9  
RANDOMIZATION:   
 
After the completion of the measures and sessions described above the participants will 
be randomly assigned to one of two groups: (a) The Dance condition will consist of 
approximately 180 minutes per week of moderate intensity African Dance, or (b) an 
Africana Culture control condition that will consist of 180 minutes per week of mixed-
programming related to African Culture, including art projects, cooking, and films.  We 
will use a computer randomization protocol that will incorporate a verification that all 
session visits have been completed and data entered into the database.  We will use a 
stratified permuted block randomization algorithm with equal allocation to one of the two 
groups.  The use of this strategy will ensure treatment balance on the two factors of age at 
study entry (=<70, >70) and gender. Once randomized, an assigned staff member will 
contact the subject via phone with the group information.  On this contact, the staff 

 
18
member will give information such as date, day, time, and location of the subject's first 
intervention session. 
 
 
1.10  EXERCISE INTERVENTION GROUPS: 
 
1.10.1 African Dance Group. Participants in the Dance condition will begin by 
dancing at reduced intensity during the first week of the program and will 
gradually increase their dancing intensity each subsequent week until they reach 
40-60% of their heart rate reserve for all of the dance class. All dance sessions 
start and end with 5-10 minutes of active stretching for the purpose of warming up 
and cooling down. As the participants will be low active at baseline, the 
prescribed intensity will be 50–65% of the maximum heart rate reserve for weeks 
one to four and 65–80% for the remainder of the program. Participants will be 
fitted with a Polar Bluetooth Smart heart rate sensor around their chest and be 
encouraged to dance within their target heart rate zone by fitness staff. 
Continuous heart rate readings of all participants will be displayed in real-time via 
the Polar Team app on an iPad or other tablet.  Certified exercise instructors will 
closely monitor attendance, intensity, frequency, and safety. Dance sessions will 
occur three days/week at one of two study sites for the duration of the 
intervention.  
 
1.10.2  Africana Culture Group. The control group will focus on learning about 
and experiencing Africana culture through interactive class discussions, lectures, 
and hand-on demonstrations. This goal for this group is 150 minutes of contact 
per week so the social component of the Dance intervention is matched. However, 
crucially, the control group will not participant in any aerobic activities; the 
majority of their activities will be conducted in a sitting position. Adherence is 
also tracked in this group, and study participants are encouraged to attend as many 
classes as possible of the offered sessions (3 classes per week).  Each class is 
expected to last 60 minutes with 5-10 minutes for taking attendance and making 
administrative announcements at the beginning/end of the class.  
 
Session Compliance. Participants in the study will be completing the African 
Dance classes or Culture classes under supervised conditions.  We will monitor 
compliance during the classes by having trainers or staff monitor attendance, 
duration of the dance, ratings of perceived exertion, and heart rate intensity 
throughout the class period. 
 
Based on the above, we have operationally defined compliance to the intervention 
as those participants meeting the prescription of either 150 minutes per week of 
moderate intensity Dance (Group 1), or 150 minutes per week of Africana Culture 
class (Group 2).  Compliance to these prescriptions will be based on the 
information gathered from the supervised sessions.  
 
1.11 ANALYSIS PLAN 

 
19
Our analysis plan has proposed an intent-to-treat analysis where all participants, 
regardless of whether they complete all sessions, will be invited to return for follow-up 
assessments. However, there will likely be some participants that refuse to return for 
follow-up assessments. “Lost to follow up” will be defined here as missing data that is 
contributing to the primary outcomes (executive functioning and hippocampal volume).  
The reason will be recorded (i.e., missed visit due to traveling, illness).  These criteria 
and documentation will also be applied for any discontinued subjects with the reasons for 
discontinuation being recorded (i.e., moving out of state).   
 
We propose to use all available data in the planned analysis for testing our primary 
outcomes. We will assess the missingness of data consistent with the assumptions of the 
modeling approach described above. That is, we will examine the randomness of missing 
data and examine if the data is missing completely at random (MCAR) or missing at 
random (MAR). Parameters of the GLMM will be estimated using the maximum 
likelihood estimation or restricted maximum likelihood methods that are known to 
produce consistent and efficient estimates under MAR.  
 
Imaging data analysis. We will first analyze each imaging outcome (e.g., 
volume) separately from every other imaging outcome (e.g., fMRI). But, once 
voxel-wise associations related to the intervention are established, we could test, 
using hierarchical regression, the relative significance of each imaging measure to 
explain improvements in cognitive function with the intervention.  
 
1.12 
PARTICIPANT SAFETY: 
The safety of study participants will be monitored throughout the study.  Study 
participants will undergo an extensive screening prior to entering the trial to determine 
that it is safe for them to participate in the intervention.  Safety is continuously monitored 
during the intervention during three supervised sessions per week.  We are aware of the 
potential for serious adverse events (AEs) to occur with any type of exercise training. As 
such, the trial will take measures to reduce the risk of any adverse events or serious 
adverse events from occurring. All individuals involved in human subject’s research 
where exercise training is involved, are trained and certified in CPR and First Aid. 
Included in the exercise stress testing room is an automated external defibrillator (AED), 
should it be deemed necessary. Lastly, protocols are currently in place to respond to any 
adverse events that include contacting emergency response personnel and facilitating 
their arrival to the correct rooms within the buildings at each intervention site.  
The REACT II primary investigator has full responsibility for the safety of study 
participants.  The Data Safety Monitoring Board (DSMB), is responsible for objectively 
monitoring study data for evidence of adverse effects attributed to the intervention.  The 
DSMB also has the authority to recommend changes or pausing the trial until problems 
are resolved.  All AEs experienced by the participant during the study (starting from 
consent signing until the end of study outcome collection) are to be documented and 
reported.  Serious adverse events will be reported to the DSMB and the IRB.  The 
REACT II trial will track the occurrence of: 

 
20
•  Serious Adverse Events (SAE) 
•  Unexpected events  
•  Unfavorable medical events that occur during intervention sessions 
 
The trial has created two forms for adverse event reporting. These documents have been 
created based on the belief that trainers and staff should not be responsible for 
determining whether the event is related to the intervention or whether/how it should be 
reported to the IRB and DSMB.  Only the PI will determine if the event is (a) expected or 
unexpected, and (b) related to the intervention. Based on responses to these questions, 
regardless of seriousness or relatedness, the trainer or dance instructor will complete a 
form documenting an adverse event.  We have created a brief form for trainers and 
instructors (REACT II Adverse Event Form for Trainers) for this purpose. Trainers or 
staff would first document the event on this form. This form allows staff to circle the 
reported event (or provide an event not listed on the form). This completed document 
would be sent to the project coordinator who would then speak to the trainer and/or 
participant to find out more information about the event. The project coordinator would 
then complete the REACT II Event Evaluation Form based on this communication. This 
form has several sections with boxes available for documenting the chronicity (single 
occurrence, intermittent, persistent), whether the event was resolved or not, and whether 
it was related to the intervention and expected or unexpected. In particular, these forms 
are intended to clarify for the investigators, the IRB, and the DSMB, whether the adverse 
event was related to the intervention, and whether it was expected or unexpected.  An 
example of an expected adverse event from the dance intervention would be muscle 
soreness which would be listed as a known risk in the IRB. An unexpected adverse event 
related to the intervention would be if someone falls during a class and injures an ankle. 
The PI will oversee the determination of these events and if there is any question about 
whether the event was related to the intervention, and its expectedness, the event will be 
discussed during weekly staff meetings.  For DSMB purposes, all adverse events that are 
reported will be recorded and separated based on whether the event was related to the 
intervention, expectedness, severity, chronicity, and resolution. 
 
1.13 DATA MANAGEMENT: 
 
We appreciate the challenges associated with the organization, execution, management, 
and analysis of a clinical trial of this kind and recognize the importance of frequent 
communication between staff, students, analysts, and investigators. Protection of subject 
privacy and safety, meticulous QC, and prudent organization is the bedrock for success of 
a study like this, which will require a sizeable team of staff and students. For this study, 
Dr. Erickson will maintain overall responsibility for DM and QC.  Dr. Kang 
(biostatistician) will monitor database integrity for missing data, errors, outliers, and 
distributions.  
 
IT staff will control permissions to the database to ensure proper access and DM by staff, 

 
21
students, and investigators. We will store and link all behavioral and assay data on a 
HIPAA secure cloud-based server (REDcap) and may use other applications (e.g., the 
Flywheel application) for securely storing and accessing imaging data from the imaging 
center.  
Data entry to the REDcap database will be completed within the BACH Lab that is 
directed by PI Erickson. The data forms in REDcap are similar to the paper version of the 
forms that will be completed by participants and staff. All participant data will be stored 
and archived on a secure server.  The server will be set for safe mode that allows two 
copies of each data to be saved.  The data server will have a hard drive array, which is 
composed of a few hard drive disks. If one or two of the disks fail, the rest of the disks 
will back up the data of the failed disks automatically. By having the database on 
REDCap, all data is secure in case of a natural disaster or other calamity.   
 
Missed Visits: All outcome collection must be reported and stored in the database.  
Therefore, if an outcome visit is missed or not collected, a missed visit form must be 
completed in REDCap.  Once a missed visit form is completed, the data management 
team will indicate in the database that the outcome data for the specific measure is missed 
to follow up.  All missing data in the database will require additional documentation 
regarding whether the data are “lost to follow up” or has been collected but there was a 
problem with transferring the data to the lab. 
 
The missed visit form has three sections that must be completed: 
• Time point of the missed visit 
• Outcome that was missed 
• Reason the outcome was missed 
 
If a study participant misses multiple outcome measures during the same time point, one 
missed visit form can be completed if the reason missed is the same for each measure.  
Thus, staff do not have to complete a new form for each missed outcome for the same 
time point.  For example, at follow-up, if the study participant missed the cognitive 
session and blood draw because the participant moved out of the area, this information 
could be completed on one missed visit form. If this study participant would also miss the 
baseline physical activity monitoring, a new form must be generated since this is a 
different time point. 
 
1.14 QUALITY CONTROL: 
This RCT demands rigorous QC to ensure consistency of the intervention procedures and 
protocols. Staff will be trained early in the first year to standardize protocols. We will 
also hold weekly meetings with all staff to ensure continuation of all protocols. Reports 
of QC will be a standard agenda item for Data Safety and Monitoring Board (DSMB) 
meetings. During the course of the study, we anticipate a turnaround of staff, graduate 
and undergraduate assistants, and these QC procedures will ensure compliance and 
uniformity of study protocol for the duration of the project. 

 
22
1.14.1 Cognitive and MRI Quality Control. To maintain QC of the cognitive 
data, all possible administrators will receive QC training in Year 01 to administer 
the tests in a standardized way. These certification sessions will be conducted 
annually for maintenance of QC.  
MR sequences will be stablished and piloted before the trial begins. The new joint 
Pitt-CMU Imaging Center is anticipated to be the location for the REACT II 
scans, which will have a research dedicated Siemens 3T machine. We will have 
monthly QC checks using phantoms and QC will be monitored for any changes 
over time. Before the start of the intervention, several staff members will be 
scanned to ensure equivalent contrast and image quality for each sequence. All 
imaging data will be uploaded to a server and will be examined by Dr. Erickson’s 
laboratory to assess QC, proper sequences, and site- specific effects.  
 
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Statistical Analysis Plan 
 
 
 

 
28
Power and Statistical Analysis: We will analyze in an intent-to-treat (ITT) manner such 
that all participants, regardless of whether they complete the intervention, will be invited 
to return for the follow-up sessions and will be included in primary analyses. Secondary 
analyses will be conducted using a per-protocol approach, which restricts the analysis to 
the participants that completed the intervention. All cognitive and neuroimaging data will 
be interrogated for normality and any non-normal data will be transformed. Any data that 
cannot be transformed will be analyzed using non-parametric tests. Non-parametric 
regression models will be used for continuous variables when necessary. Outlier de-
weighting will be conducted to remove the influence of anomalous data. All analyses will 
be two-tailed. We will first summarize baseline demographic and brain characteristics of 
the sample and intervention groups by conducting Pearson, Spearman, and Chi-square 
statistics as appropriate. Our primary goals are to examine whether the intervention 
improves cognitive and brain health. To test these hypotheses, we propose to use a General 
Linear Mixed Model (GLMM) in standard neuroimaging and statistical packages. Effects 
of Time (baseline, 6-month), Group (Dance, Education), and Time by Group interactions 
will be examined. Post-hoc comparisons using least square means will decompose any 
significant interactions and will be plotted to illustrate the direction of the effect. Mean 
differences between groups for all cognitive and neuroimaging outcome measures will be 
derived using linear contrasts and multiple comparisons will be corrected by standard 
protocols. Differences in baseline characteristics will be accounted for by using covariance 
adjusted models. 
We will describe differences in baseline characteristics between participants with 
complete versus incomplete follow-up to assess any bias (e.g., age) in those who do not 
return for follow-up. However, according to ITT analyses, all participants including those 
that do not complete the intervention will be analyzed as part of the trial. Using hierarchical 
regression models, we will be able to explore whether changes in any cognitive or 
neuroimaging metric (e.g., white matter integrity) varies as a function of improvements in 
PA or fitness independently of assigned group. We also appreciate that there will be 
significant individual variability in factors such as body mass, blood pressure, fitness level, 
or SES. Instead of modeling this variation as ‘noise’ we plan to take advantage of the 
variability to further explore, independently of group assignment, the associations between 
cognitive and brain imaging metrics and initial levels and individual change trajectories. 
Main effects and interaction terms will be modeled in these regression analyses and time-
dependent changes will be explored and illustrated by scatter plots. These analyses will be 
useful for generating future hypotheses and questions.  
Power Analyses:  Our proposed sample size of 180, with randomization of 90 participants 
in each group, is based on effect sizes from preliminary data. Even when accounting for 
attrition and retention of ~70% of participants (65 in each group), we are sufficiently 
powered to detect effects in cognitive and brain outcomes and to test for mediation. 
Cognitive performance: Our prior PA interventions have found moderate sized effects 
on cognitive function after 6-months with a Cohen’s d ranging from 0.40 to 0.80 depending 
on the outcome. In our analysis of the pilot data from the African Dance intervention with 
only 19 participants (9 in the Dance group) we estimate similar or greater effect sizes of 
~.70. If we estimate an effect of 0.70, 65 participants per group after attrition will provide 
us with >91% power to examine our primary hypotheses. 
Brain volumetrics: Our prior 6-12 month PA interventions have used between 30 and 

 
29
60 subjects per group with Cohen’s d ranging between 0.40 and 0.50 using similar analysis 
approaches. Cross-sectional research has reported significant effects of PA on brain 
volume with only 32 subjects and effect sizes between 0.50 – 0.60. Preliminary data on 37 
African Americans from one of our prior studies suggest that cross-sectional differences 
between African Americans engaging in PA compared to those not engaging in PA are 
larger than for whites (Cohen’s d = 1.83). These studies argue for a moderate-to-large effect 
of PA on brain volume depending on the sample, the measure of PA and fitness, and the 
brain metric used. If we estimate a conservative effect size of 0.50, 65 participants per 
group will be sufficient to detect differences in brain volume at 81% power.  
Diffusion tensor imaging: Changes in white matter have been detected in PA 
interventions in as little as 6-months with only 50 subjects. In a 12-month PA intervention, 
we found increased FA with only 35 subjects in each group with an estimated effect size 
of 0.70.Based on an estimated effect size of 0.75, we should have >85% power with 65 
participants per group to test our main hypotheses as well as enough power for exploratory 
analyses.  
Task-evoked activity: Task-evoked brain imaging studies of PA have found statistically 
significant effects with 30 - 50 subjects per group with effect sizes ranging between 1.0 
and 1.3 depending on the region examined and the task employed. Cross-sectional studies 
of fitness on brain activity report even larger effects up to 1.70. These patterns indicate a 
large effect size of PA on brain function, so 65 participants per group will provide us with 
substantial power to test our main aims and hypotheses. 
Connectivity:  With only 65 people, we have shown that a PA intervention is 
effective at enhancing functional connectivity in prefrontal-inhibitory networks. The 
difference between the groups for prefrontal cortex connectivity was .15 with a standard 
deviation of .10 suggesting an effect size of 1.5 (Cohen’s d). Therefore, similar to the 
effect sizes and power for the other measures, 65 participants per group should be 
sufficient for detecting changes as a function of the intervention with >85% power. 
 
Given the continued challenges of navigating the COVID-19 pandemic, we requested 
to modify our recruitment/randomization accrual and targeted sample size for the study 
titled “Rhythm Experience and Africana Culture Trial (REACT II)” on August 29th, 
2023. We have determined that we will have sufficient statistical power to test our 
primary aims with a reduction in the targeted sample size from 180 to 150.  
The recommended changes were approved by the meeting of the Data Safety and 
Monitoring Board on August 29, 2023.