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Shahbazi N, Heirani A, Amiri E, da Silva Machado DG. Effects of repeated unihemispheric concurrent dual-site tDCS and virtual reality games on motor coordination of sedentary adolescent girls. BEHAVIORAL AND BRAIN FUNCTIONS : BBF 2024; 20:20. [PMID: 39174998 PMCID: PMC11342668 DOI: 10.1186/s12993-024-00247-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND This study investigated the effects of repetitive unihemispheric concurrent dual-site anodal transcranial direct current stimulation (a-tDCSUHCDS) associated with the use of virtual reality games (VR) on the motor coordination of sedentary adolescent girls. METHODS Thirty-six inactive adolescent girls were randomly assigned into 3 groups (n = 12 per group): (1) VR + a-tDCSUHCDS, (2) VR + sham-tDCSUHCDS, and (3) Control. The VR + a-tDCSUHCDS and VR + s-tDCSUHCDS groups received the intervention three times a week for four weeks. In each experimental session, participants first received either 20 min of a-tDCSUHCDS (2 mA at each anodal electrode) targeting the primary motor cortex (M1) and the left dorsolateral prefrontal cortex (DLPFC) or sham and then performed VR for 1 h. The control group received no intervention. Eye-hand coordination (EHC) and bimanual coordination (BC) were measured at baseline, post-intervention, and two weeks later (retention test) using the automatic scoring mirror tracer and continuous two-arm coordination test, respectively. RESULTS Results showed that the EHC was significantly higher in the VR + a-tDCS and VR + s-tDCS groups at post-intervention (all ps< 0.001) and the retention test (all ps< 0.001) compared to the control group. Moreover, the EHC was significantly higher in the VR + a-tDCS group compared to the VR + s-tDCS group (p = 0.024) at the retention. Similarly, VR + a-tDCS and VR + s-tDCS improved BC compared to the control group at post-intervention (all ps< 0.001) and retention test (all ps< 0.001). In addition, higher BC was observed in the VR + a-tDCS group compared to the VR + s-tDCS group (p< 0.001) at the retention test. CONCLUSIONS Our results suggest that adding a-tDCSUHCDS to VR over 12 sessions may have an additional effect on VR training for improving and retaining motor coordination in sedentary adolescent girls.
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Affiliation(s)
- Nasrin Shahbazi
- Department of Motor Behavior and Corrective Exercises, Faculty of Sport Sciences, Razi University, Kermanshah, Iran
| | - Ali Heirani
- Department of Motor Behavior and Corrective Exercises, Faculty of Sport Sciences, Razi University, Kermanshah, Iran.
| | - Ehsan Amiri
- Exercise Metabolism and Performance Lab (EMPL), Department of Exercise Physiology, Faculty of Sport Sciences, Razi University, Kermanshah, Iran
| | - Daniel Gomes da Silva Machado
- Research Group in Neuroscience of Human Movement (NeuroMove), Department of Physical Education, Federal University of Rio Grande do Norte, Natal, RN, Brazil
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González-Zamorano Y, José Sánchez-Cuesta F, Moreno-Verdú M, Arroyo-Ferrer A, Fernández-Carnero J, Chaudhuri KR, Fieldwalker A, Romero JP. TDCS for parkinson's disease disease-related pain: A randomized trial. Clin Neurophysiol 2024; 161:133-146. [PMID: 38479239 DOI: 10.1016/j.clinph.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 12/05/2023] [Accepted: 01/04/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To evaluate the effects of transcranial direct current stimulation (tDCS) on Parkinson's disease (PD)-related pain. METHODS This triple-blind randomized controlled trial included twenty-two patients (age range 38-85, 10 male) with PD-related pain. Eleven subjects received ten sessions of 20 minutes tDCS over the primary motor cortex contralateral to pain at 2 mA intensity. Eleven subjects received sham stimulation. Outcome measures included changes in the Kinǵs Parkinsońs Pain Scale (KPPS), Brief Pain Inventory (BPI), widespread mechanical hyperalgesia (WMH), temporal summation of pain (TS), and conditioned pain modulation (CPM). RESULTS Significant differences were found in KPPS between groups favoring the active-tDCS group compared to the sham-tDCS group at 15-days follow-up (p = 0.014) but not at 2 days post-intervention (p = 0.059). The active-group showed significant improvements over the sham-group after 15 days (p = 0.017). Significant changes were found in CPM between groups in favor of active-tDCS group at 2 days post-intervention (p = 0.002) and at 15 days (p = 0.017). No meaningful differences were observed in BPI or TS. CONCLUSIONS tDCS of the primary motor cortex alleviates perceived PD-related pain, reduces pain sensitization, and enhances descending pain inhibition. SIGNIFICANCE This is the first study to test and demonstrate the use of tDCS for improving PD-related pain.
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Affiliation(s)
- Yeray González-Zamorano
- International Doctorate School, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain; Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28933 Alcorcón, Spain; Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain; Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain.
| | - Francisco José Sánchez-Cuesta
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain.
| | - Marcos Moreno-Verdú
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain
| | - Aida Arroyo-Ferrer
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain.
| | - Josué Fernández-Carnero
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28933 Alcorcón, Spain; Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain.
| | - K Ray Chaudhuri
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom; Parkinson's Foundation Centre of Excellence, King's College Hospital, London, United Kingdom.
| | - Anna Fieldwalker
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Juan Pablo Romero
- Cognitive Neuroscience, Pain and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, Madrid, Spain; Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, Pozuelo de Alarcón, Spain; Faculty of Experimental Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain; Brain Damage Unit, Beata María Ana Hospital, 28007 Madrid, Spain.
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Gurdiel-Álvarez F, González-Zamorano Y, Lerma-Lara S, Gómez-Soriano J, Sánchez-González JL, Fernández-Carnero J, Navarro-López V. Transcranial Direct Current Stimulation (tDCS) Effects on Quantitative Sensory Testing (QST) and Nociceptive Processing in Healthy Subjects: A Systematic Review and Meta-Analysis. Brain Sci 2023; 14:9. [PMID: 38275514 PMCID: PMC10813344 DOI: 10.3390/brainsci14010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND The aim of this study is to determine the effect that different tDCS protocols have on pain processing in healthy people, assessed using quantitative sensory tests (QST) and evoked pain intensity. METHODS We systematically searched in EMBASE, CINAHL, PubMed, PEDro, PsycInfo, and Web of Science. Articles on tDCS on a healthy population and regarding QST, such as pressure pain thresholds (PPT), heat pain thresholds (HPT), cold pain threshold (CPT), or evoked pain intensity were selected. Quality was analyzed using the Cochrane Risk of Bias Tool and PEDro scale. RESULTS Twenty-six RCTs were included in the qualitative analysis and sixteen in the meta-analysis. There were no significant differences in PPTs between tDCS and sham, but differences were observed when applying tDCS over S1 in PPTs compared to sham. Significant differences in CPTs were observed between tDCS and sham over DLPFC and differences in pain intensity were observed between tDCS and sham over M1. Non-significant effects were found for the effects of tDCS on HPTs. CONCLUSION tDCS anodic over S1 stimulation increases PPTs, while a-tDCS over DLPFC affects CPTs. The HPTs with tDCS are worse. Finally, M1 a-tDCS seems to reduce evoked pain intensity in healthy subjects.
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Affiliation(s)
- Francisco Gurdiel-Álvarez
- International Doctorate School, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain; (F.G.-Á.); (Y.G.-Z.)
- Cognitive Neuroscience, Pain, and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, 28032 Madrid, Spain
| | - Yeray González-Zamorano
- International Doctorate School, Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain; (F.G.-Á.); (Y.G.-Z.)
- Cognitive Neuroscience, Pain, and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, 28032 Madrid, Spain
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28032 Madrid, Spain;
- Brain Injury and Movement Disorders Neurorehabilitation Group (GINDAT), Institute of Life Sciences, Francisco de Vitoria University, 28223 Pozuelo de Alarcón, Spain
| | - Sergio Lerma-Lara
- Department of Physical Therapy, Centro Superior de Estudios Universitarios La Salle, Universidad Autónoma de Madrid, 28023 Madrid, Spain;
| | - Julio Gómez-Soriano
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing, Universidad Castilla La Mancha, 45071 Toledo, Spain;
| | - Juan Luis Sánchez-González
- Faculty of Nursing and Physiotherapy, Department of Nursing and Physiotherapy, Instituto de Investigación Biomédica de Salamanca (IBSAL), University of Salamanca, Campus Miguel de Unamuno s/n, 37007 Salamanca, Spain;
| | - Josué Fernández-Carnero
- Cognitive Neuroscience, Pain, and Rehabilitation Research Group (NECODOR), Faculty of Health Sciences, Rey Juan Carlos University, 28032 Madrid, Spain
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28032 Madrid, Spain;
- La Paz Hospital Institute for Health Research, IdiPAZ, 28922 Madrid, Spain
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, 28670 Madrid, Spain
| | - Víctor Navarro-López
- Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, 28032 Madrid, Spain;
- Movement Analysis, Biomechanics, Ergonomics, and Motor Control Laboratory, Faculty of Health Sciences, Rey Juan Carlos University, 28922 Madrid, Spain
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Banaei P, Tadibi V, Amiri E, Machado DGDS. Concomitant dual-site tDCS and dark chocolate improve cognitive and endurance performance following cognitive effort under hypoxia: a randomized controlled trial. Sci Rep 2023; 13:16473. [PMID: 37777571 PMCID: PMC10542360 DOI: 10.1038/s41598-023-43568-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 09/26/2023] [Indexed: 10/02/2023] Open
Abstract
Ten male cyclists were randomized into four experimental conditions in this randomized, cross-over, double-blind, and sham-controlled study to test the combined effect of acute dark chocolate (DC) ingestion and anodal concurrent dual-site transcranial direct current stimulation (a-tDCS) targeting M1 and left DLPFC on cognitive and whole-body endurance performance in hypoxia after performing a cognitive task. Two hours before the sessions, chocolate was consumed. After arriving at the lab, participants completed an incongruent Stroop task for 30 min in hypoxia (O2 = 13%) to induce mental fatigue, followed by 20 min of tDCS (2 mA) in hypoxia. Then, in hypoxia, they performed a time-to-exhaustion task (TTE) while measuring physiological and psychophysiological responses. Cognitive performance was measured at baseline, after the Stroop task, and during and after TTE. TTE in 'DC + a-tDCS' was significantly longer than in 'white chocolate (WC) + a-tDCS' and WC + sham-tDCS'. The vastus medialis muscle electromyography amplitude was significantly higher in 'DC + a-tDCS' and 'DC + sham-tDCS' than in 'WC + sh-tDCS'. During and after the TTE, choice reaction time was significantly lower in 'DC + a-tDCS' compared to 'WC + sh-tDCS'. Other physiological or psychophysiological variables showed no significant differences. The concurrent use of acute DC consumption and dual-site a-tDCS might improve cognitive and endurance performance in hypoxia.
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Affiliation(s)
- Parisa Banaei
- Exercise Metabolism and Performance Lab (EMPL), Department of Exercise Physiology, Faculty of Sport Sciences, Razi University, University Avenue, Taq-e Bostan, Kermanshah, 6714414971, Iran
| | - Vahid Tadibi
- Exercise Metabolism and Performance Lab (EMPL), Department of Exercise Physiology, Faculty of Sport Sciences, Razi University, University Avenue, Taq-e Bostan, Kermanshah, 6714414971, Iran.
| | - Ehsan Amiri
- Exercise Metabolism and Performance Lab (EMPL), Department of Exercise Physiology, Faculty of Sport Sciences, Razi University, University Avenue, Taq-e Bostan, Kermanshah, 6714414971, Iran
| | - Daniel Gomes da Silva Machado
- Research Group in Neuroscience of Human Movement (NeuroMove), Department of Physical Education, Federal University of Rio Grande do Norte, Natal, RN, 59078-970, Brazil
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Kold S, Graven-Nielsen T. Modulation of central pain mechanisms using high-definition transcranial direct current stimulation: A double-blind, sham-controlled study. Eur J Pain 2023; 27:303-315. [PMID: 36451616 PMCID: PMC10107535 DOI: 10.1002/ejp.2060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 11/25/2022] [Accepted: 11/29/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND The use of high-definition transcranial direct current stimulation (HD-tDCS) has shown analgesic effects in some chronic pain patients, but limited anti-nociceptive effects in healthy asymptomatic subjects. METHODS This double-blinded sham-controlled study assessed the effects of HD-tDCS applied on three consecutive days on central pain mechanisms in healthy participants with (N = 40) and without (N = 40) prolonged experimental pain induced by intramuscular injection of nerve growth factor into the right hand on Day 1. Participants were randomly assigned to Sham-tDCS (N = 20 with pain, N = 20 without) or Active-tDCS (N = 20 with pain, N = 20 without) targeting simultaneously the primary motor cortex and dorsolateral prefrontal cortex for 20 min with 2 mA stimulation intensity. Central pain mechanisms were assessed by cuff algometry on the legs measuring pressure pain sensitivity, temporal summation of pain (TSP) and conditioned pain modulation (CPM), at baseline and after HD-tDCS on Day 2 and Day 3. Based on subject's assessment of received HD-tDCS (sham or active), they were effectively blinded. RESULTS Compared with Sham-tDCS, Active-tDCS did not significantly reduce the average NGF-induced pain intensity. Tonic pain-induced temporal summation at Day 2 and Day 3 was significantly lower in the NGF-pain group under Active-tDCS compared to the pain group with Sham-tDCS (p ≤ 0.05). No significant differences were found in the cuff pressure pain detection/tolerance thresholds or CPM effect across the 3 days of HD-tDCS in any of the four groups. CONCLUSION HD-tDCS reduced the facilitation of TSP caused by tonic pain suggesting that efficacy of HD-tDCS might depend on the presence of sensitized central pain mechanisms.
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Affiliation(s)
- Sebastian Kold
- Center for Neuroplasticity and Pain (CNAP), Aalborg University, Aalborg, Denmark
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Erdoğan ET, Küçük Z, Eskikurt G, Kurt A, Ermutlu N, Karamürsel S. Single Session Anodal Transcranial Direct Current Stimulation on Different Cortical Areas. J PSYCHOPHYSIOL 2022. [DOI: 10.1027/0269-8803/a000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. Transcranial direct current stimulation (tDCS) studies in healthy volunteers have shown conflicting results in terms of modulation in pain thresholds. The aim of this study was to investigate how single session anodal tDCS and modulated tDCS (mtDCS) of distinct cortical areas affected pain and perception thresholds in healthy participants. Five different stimulation conditions were applied at different cortical sites to 20 healthy volunteers to investigate the effects of tDCS and mtDCS (20 Hz) on pain and perception thresholds. TDCS over the motor cortex (M1), mtDCS over the motor cortex, tDCS over the dorsolateral prefrontal cortex (DLPFC), mtDCS of the DLPFC, and mtDCS over the occipital cortex were the stimulation conditions. All of the stimulations were anodal. The stimulations were given in a randomized order at 20-minute intervals. For comparison, electrical pain and perception thresholds were obtained from the right middle finger before and during the tDCS. After each measurement, participants were asked to give a score to their pain. In repeated measures analysis of variance (RM-ANOVA) test, the Condition × Time interaction showed no significant influence on changes in pain, perception thresholds, and pain scores ( p = .48, p = .89, and p = .50, respectively). However, regardless of the condition types, there was a significant difference in pain and perceptual thresholds during tDCS ( p = .01, p = .025, respectively). Our findings did not support difference in pain and perception modulation by a single session anodal tDCS over M1 and DLPFC compared to the occipital cortex in healthy volunteers. The increase in all thresholds during tDCS, irrespective of conditions, and peripheral sensations, including an active control group, taken together, suggest a placebo effect of active tDCS. Future studies about pain and perception in healthy subjects should consider the level of experimental pain and a strong placebo effect.
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Affiliation(s)
- Ezgi Tuna Erdoğan
- Department of Physiology, School of Medicine, Koç University, Istanbul, Turkey
| | - Zeynep Küçük
- Department of Psychology, Faculty of Science and Literature, Halic University, Istanbul, Turkey
| | - Gökçer Eskikurt
- Department of Physiology, Faculty of Medicine, Istinye University, Istanbul, Turkey
| | - Adnan Kurt
- Department of Physiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Numan Ermutlu
- Department of Physiology, Faculty of Medicine, Istanbul Health and Technology University, Istanbul, Turkey
| | - Sacit Karamürsel
- Department of Physiology, School of Medicine, Koç University, Istanbul, Turkey
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Jiang X, Wang Y, Wan R, Feng B, Zhang Z, Lin Y, Wang Y. The effect of high-definition transcranial direct current stimulation on pain processing in a healthy population: A single-blinded crossover controlled study. Neurosci Lett 2022; 767:136304. [PMID: 34695451 DOI: 10.1016/j.neulet.2021.136304] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 12/28/2022]
Abstract
Transcranial direct current stimulation (tDCS) is increasingly used in pain treatment. tDCS targeting both primary motor cortex (M1) and dorsolateral prefrontal cortex (DLPFC) may modulate the descending pain inhibitory system, however, it remains controversial regarding the optimal stimulation region for pain modulation. Therefore, this study aimed to explore the effects of high-definition anodic stimulation of M1 and DLPFC on conditioned pain modulation (CPM) and pain thresholds and establish a preferred stimulation setting. Twenty-six healthy adults were randomly assigned to M1-tDCS, DLPFC-tDCS, or sham-tDCS groups. During the three sessions, each participant received an active or sham stimulation of 2 mA for 20 min, with at least 3 days' interval between sessions. Quantitative sensory tests were performed to obtain pressure pain threshold (PPT), cold pain threshold (CPT), and CPM before and after the tDCS intervention. Only M1-tDCS significantly increased CPM in healthy individuals compared with sham control (P = 0.004). No statistically significant difference was found in PPT and CPT between tDCS vs. sham control (P > 0.05). Our findings further support the important role of M1 as a target in pain regulation. Further large-scale, multicenter studies in chronic pain populations are needed to validate the alterations of distinct target brain regions related to pain and thus for an optimal target stimulation strategy in pain management.
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Affiliation(s)
- Xue Jiang
- Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China; Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yafei Wang
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ruihan Wan
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Sport Rehabilitation, Shenyang Sport University, Shenyang, China
| | - Beibei Feng
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Orthopedics & Traumatology, The University of Hong Kong, HKSAR, China
| | - Ziping Zhang
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China; Department of Sport Rehabilitation, Shenyang Sport University, Shenyang, China
| | - Yangyang Lin
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuling Wang
- Department of Rehabilitation Medicine, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.
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