Assessing the synergistic effectiveness of intermittent theta burst stimulation and the vestibular ocular reflex rehabilitation protocol in the treatment of Mal de Debarquement Syndrome: a randomised controlled trial

INTRODUCTION

Mal de Debarquement Syndrome (MdDS) is a rare central vestibular disorder characterised by a constant sensation of motion (rocking, swaying, bobbing), which typically arises after motion experiences (e.g. sea, air, and road travel), though can be triggered by non-motion events. The current standard of care is non-specific medications and interventions that only result in mild-to-moderate improvements. The vestibular ocular reflex (VOR) rehabilitation protocol, a specialised form of rehabilitation, has shown promising results in reducing symptoms amongst people with MdDS. Accumulating evidence suggests that it may be possible to augment the effects of VOR rehabilitation via non-invasive brain stimulation protocols, such as theta burst stimulation (TBS).

METHODS

The aim of this randomised controlled trial was to evaluate the effectiveness of intermittent TBS (iTBS) over the dorsolateral prefrontal cortex in enhancing the effectiveness of a subsequently delivered VOR rehabilitation protocol in people with MdDS. Participants were allocated randomly to receive either Sham (n = 10) or Active (n = 10) iTBS, followed by the VOR rehabilitation protocol. Subjective outcome measures (symptom ratings and mental health scores) were collected 1 week pre-treatment and for 16 weeks post-treatment. Posturography (objective outcome) was recorded each day of the treatment week.

RESULTS

Significant improvements in subjective and objective outcomes were reported across both treatment groups over time, but no between-group differences were observed.

DISCUSSION

These findings support the effectiveness of the VOR rehabilitation protocol in reducing MdDS symptoms. Further research into iTBS is required to elucidate whether the treatment has a role in the management of MdDS. TRN: ACTRN12619001519145 (Date registered: 04 November 2019).

Bilateral Corticomotor Reorganization and Symptom Development in Response to Acute Unilateral Hamstring Pain: A Randomized, Controlled Study

Accumulating evidence demonstrates that pain induces adaptations in the corticomotor representations of affected muscles. However, previous work has primarily investigated the upper limb, with few studies examining corticomotor reorganization in response to lower limb pain. This is important to consider, given the significant functional, anatomical, and neurophysiological differences between upper and lower limb musculature. Previous work has also focused on unilateral corticomotor changes in response to muscle pain, despite an abundance of literature demonstrating that unilateral pain conditions are commonly associated with bilateral motor dysfunction. For the first time, this study investigated the effect of unilateral acute hamstring pain on bilateral corticomotor organization using transcranial magnetic stimulation (TMS) mapping. Corticomotor outcomes (TMS maps), pain, mechanical sensitivity (pressure pain thresholds), and function (maximal voluntary contractions) were recorded from 28 healthy participants at baseline. An injection of pain-inducing hypertonic (n = 14) or pain-free isotonic (n = 14) saline was then administered to the right hamstring muscle, and pain ratings were collected every 30 seconds until pain resolution. Follow-up measures were taken immediately following pain resolution and at 25, 50, and 75 minutes post-pain resolution. Unilateral acute hamstring pain induced bilateral symptom development and changes in corticomotor reorganization. Two patterns of reorganization were observed-corticomotor facilitation and corticomotor depression. Corticomotor facilitation was associated with increased mechanical sensitivity and decreased function bilaterally (all P < .05). These effects persisted for at least 75 minutes after pain resolution. PERSPECTIVE: These findings suggest that individual patterns of corticomotor reorganization may contribute to ongoing functional deficits of either limb following acute unilateral lower limb pain. Further research is required to assess these adaptations and the possible long-term implications for rehabilitation and reinjury risk in cohorts with acute hamstring injury.

The Influence of Stress on Student Performance during Simulation-based Learning: A Pilot Randomized Trial

Background

Simulation-based learning is an important educational medium that is being implemented increasingly for the purpose of improved patient care and safety. However, there is evidence to suggest that simulation-based education (SBE) may increase anxiety, as illustrated through self-reporting and physiological responses. Despite such data, no studies have investigated whether anxiety and stress can be manipulated through SBE scenario design and delivery to facilitate optimal learning conditions.

Objective

This pilot study examined perceived anxiety and physiological stress experienced by entry-level physiotherapy students while learning a skill using SBE and the relationship between this anxiety and their subsequent skill performance.

Methods

Final-year physiotherapy students were randomly allocated to one of three SBE experiences: low, medium, or high stress. The experiences were designed to induce increasing levels of stress and anxiety. Performance of the learned skill (endotracheal airway suctioning) was measured after the SBE using a bespoke assessment form. Cortisol levels, heart rate, and perceived anxiety measurements (State-Trait Anxiety Inventory and visual analog scale) were also collected.

Results

Twenty-seven participants completed the trial. There were significant differences in perceived stress and physiological response between the groups. The low-stress group demonstrated significantly better performance of airway suctioning than the higher-stress groups (P = 0.02). Higher anxiety was correlated with poorer skill performance (r = -0.410).

Conclusions

Students report SBE to be stressful, and scenarios themselves can influence the stress and anxiety experienced. Greater stress is associated with poor learning outcomes during SBE. Healthcare educators involved in SBE scenario design need to consider the stress levels experienced. Future research to determine optimal stress and embed measurement of stress in SBE experiences is warranted.

Mouth Rinsing and Ingestion of Unpleasant Salty or Bitter Solutions Does Not Improve Cycling Sprint Performance in Trained Cyclists

The purpose of this study was to investigate the influence of mouth rinsing and ingesting unpleasant salty or bitter solutions on cycling sprint performance and knee extensor force characteristics. Eleven male and one female trained cyclists (age: 34 ± 9 years, maximal oxygen uptake 56.9 ± 3.9 ml·kg-1·min-1) completed a ramp test and familiarization followed by four experimental trials. In each trial, participants completed an all-out 30-s cycling sprint with knee extensor maximal voluntary contractions before and immediately after the sprint. In a randomized, counterbalanced, cross-over order, the four main trials were: a no solution control condition, water, salty (5.8%), or bitter (2 mM quinine) solutions that were mouth rinsed (10 s) and ingested immediately before the cycling sprint. There were no significant differences between conditions in mean power (mean ± SD, no solution: 822 ± 115 W, water: 818 ± 108 W, salt: 832 ± 111 W, bitter: 818 ± 105 W); peak power (no solution: 1,184 ± 205 W, water: 1,177 ± 207 W, salt: 1,195 ± 210 W, bitter: 1,184 ± 209 W); or fatigue index (no solution: 51.5% ± 5.7%, water: 50.8% ± 7.0%, salt: 51.1% ± 5.9%, bitter: 51.2% ± 7.1%) during the sprint. Maximal force and impulse declined postexercise; however, there were no significant differences between conditions in knee extensor force characteristics. The present data do not support the use of unpleasant salty or bitter solutions as an ergogenic aid to improve sprint exercise performance.

Investigating interindividual variability in corticomotor reorganization during sustained hamstring pain: A randomized experimental study

BACKGROUND

Increasing evidence suggests that pain drives maladaptive corticomotor changes that may increase susceptibility to injury and promote symptom recurrence. However, few studies have evaluated the influence of interindividual corticomotor responses to musculoskeletal pain. Existing research in this area has also been limited largely to the upper limb. This is a pertinent point, given the functional and neurophysiological differences between upper and lower limb muscles, as well as the fact that most acute sporting injuries occur in the lower limb. Accordingly, this study explored the variability of corticomotor responses to experimentally-induced sustained hamstring pain and whether specific patterns of corticomotor reorganization were associated with poorer outcomes (mechanical sensitivity, pain, or functional limitation).

METHOD

Thirty-six healthy individuals participated. Following random allocation on Day 0, the experimental group performed an eccentric exercise protocol of the right hamstring muscles to induce delayed onset muscle soreness. The control group performed repetition-matched concentric exercise that did not induce soreness. Measures of mechanical sensitivity, pain, function, and corticomotor organization were collected at baseline and on Day 2.

RESULTS AND CONCLUSIONS

Corticomotor responses to sustained hamstring pain were variable. Individuals who developed corticomotor facilitation in response to hamstring pain experienced greater mechanical sensitivity than those who developed corticomotor depression. These novel data could have implications for rehabilitation following lower limb pain or injury.

Effectiveness of non-pharmacological treatments for vestibular and oculomotor dysfunction in patients with persistent post-concussive symptoms: protocol for a systematic review and meta-analysis

INTRODUCTION

Concussion is a form of mild traumatic brain injury that disrupts brain function. Although symptoms are mostly transient, recovery can be delayed and result in persistent postconcussive symptoms (PPCS). Vestibular and oculomotor dysfunction are among the most debilitating impairments associated with PPCS. However, pharmacological interventions for these impairments are associated with deleterious side effects. Accordingly, increasing research has examined the utility of non-pharmacological interventions for PPCS. The aim of this review is to synthesise and evaluate the effectiveness of non-pharmacological interventions for the treatment of vestibular and oculomotor dysfunction for patients with PPCS.

METHODS AND ANALYSIS

Systematic searches of MEDLINE, PubMed, Web of Science and Scopus will identify randomised controlled trials employing non-pharmacological treatments for vestibular and/or oculomotor dysfunction for PPCS. Such interventions may include, but are not limited to, vestibular rehabilitation, optokinetic stimulation and vestibulo-ocular reflex exercises. Assessments of oculomotor function will include versional eye movements, vergence eye movements, visual-fixation movements and accommodation response. Assessments of vestibular function will include the Fukuda Step test, functional balance tests, force displacement tests, and subjective reports of balance disruption or vertigo. Where appropriate, meta-analyses of standardised mean differences will be conducted using a random effects model for continuous outcomes. For dichotomous outcomes (improved vs not improved following treatment), effects will be expressed as relative risk. The impact of heterogeneity will be calculated using the I² statistic. The Physiotherapy Evidence Database scale will be used to determine the methodological quality of individual studies and Grading of Recommendations, Assessment, Development and Evaluations used to assess the certainty and quality of evidence for each outcome.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42021254720.

The effect of theta burst stimulation over the primary motor cortex on experimental hamstring pain: A randomised, controlled study

Theta burst stimulation (TBS) over the primary motor cortex (M1) is an emerging technique that may have utility in the treatment of musculoskeletal pain. However, previous work exploring the analgesic effects of noninvasive brain stimulation has been limited largely to the arm or hand, despite 80% of acute musculoskeletal injuries occurring in the lower limb. This is a pertinent point, given the functional and neurophysiological differences between upper and lower limb musculature, as well as evidence suggesting that reorganization of corticomotor pathways is region-specific. This study investigated the effect of excitatory TBS on pain, function, and corticomotor organization during experimentally induced lower limb pain. Twenty-eight healthy participants attended 2 experimental sessions. On Day 0, participants completed 10 sets of 10 maximal eccentric contractions of the right hamstring muscles to induce delayed onset muscle soreness. Four consecutive blocks of either active or sham TBS were delivered on Day 2. Measures of mechanical sensitivity, pain (muscle soreness, pain intensity, pain area) function (single-leg hop distance, maximum voluntary isometric contraction, lower extremity functional scale), and corticomotor organization were recorded before and after TBS on Day 2. Pain and function were also assessed daily from Days 2 to 10. Active TBS reduced mechanical sensitivity compared to sham stimulation (P = .01). Corticomotor organization did not differ between groups, suggesting that improvements in mechanical sensitivity were not mediated by changes in M1. Subjective reports of pain intensity and function did not change following active TBS, contrasting previous reports in studies of the upper limb. PERSPECTIVE: M1 TBS reduces mechanical sensitivity associated with experimentally induced hamstring pain. Though further work is needed, these findings may hold important implications for those seeking to expedite recovery or reduce muscle sensitivity following hamstring injury.

Exploring patient perceptions of repetitive transcranial magnetic stimulation as a treatment for chronic musculoskeletal pain: a qualitative study

OBJECTIVE

Repetitive transcranial magnetic stimulation (rTMS), a form of non-invasive brain stimulation, is a novel avenue for the management of chronic musculoskeletal pain. Despite evidence for the effectiveness of rTMS in chronic pain conditions, the clinical uptake of rTMS remains limited and little is known regarding patient perceptions of this therapeutic technique.

DESIGN

Qualitative study using a phenomenological approach, reported in accordance with the Consolidated criteria for Reporting Qualitative research checklist.

SETTING

Sydney, Australia.

PARTICIPANTS

Fifteen participants were recruited from the community and completed the study. All participants had a diagnosis of chronic musculoskeletal pain, a history of seeking treatment and no prior experience with rTMS.

METHODS AND ANALYSIS

All participants completed a semistructured interview to explore overall knowledge, preconceived concerns and attitudes regarding rTMS as a treatment for chronic musculoskeletal pain. The interviews were transcribed verbatim and analysed thematically.

RESULTS

The key themes that influenced an individual's hypothetical acceptance of rTMS for chronic pain management were (1) the individual's initial impression of the equipment appearance, (2) the participant's individual history and familiarity with technology, (3) the accessibility and availability of rTMS and (4) knowledge regarding pain physiology and rTMS.

CONCLUSIONS

This was the first qualitative study to explore the perception of rTMS as a treatment among people with chronic musculoskeletal pain. RTMS appears to be accepted as a treatment option among individuals with chronic musculoskeletal pain. Developing targeted strategies to address accessibility, funding support and medical endorsements may encourage use of rTMS in a clinical chronic pain setting.

Exploring Patient Perceptions of Noninvasive Brain Stimulation: A Systematic Review

OBJECTIVE

To synthesize and critically appraise literature exploring patient perceptions regarding the therapeutic use of noninvasive brain stimulation.

MATERIAL AND METHODS

A systematic search of CINHAL, PUBMED, Web of Science, and Medline was performed. Reference lists of relevant articles were also screened. Studies exploring participant perceptions regarding the therapeutic use of noninvasive brain stimulation were eligible for inclusion. Perceptions were divided into three domains: knowledge, experience, and attitudes. Noninvasive brain stimulation was defined as any neuromodulation technique that alters brain activity but does not require invasive methods such as surgery. No restrictions were placed upon study design or participant population. Two reviewers performed data extraction and risk of bias assessment. Data relating to methodological characteristics, participant demographics, type of noninvasive brain stimulation, and nature of perceptions (knowledge, experience, or attitudes) were extracted.

RESULTS

Four studies comprising data from 163 participants met the inclusion criteria. All studies investigated perceptions of repetitive transcranial magnetic stimulation (rTMS) in psychiatric populations. Most participants perceived rTMS to be safe and beneficial, demonstrated low levels of fear, and were willing to recommend the intervention to others. No studies were found investigating patient perception of transcranial direct current stimulation (tDCS).

CONCLUSION

The findings from this review suggest that rTMS is well accepted as a therapeutic treatment among psychiatric populations, providing support for its clinical utility. Future work is needed to determine if similar findings exist for other conditions (eg, chronic pain) and for other therapeutic forms of brain stimulation (eg, tDCS).

The Relationship Between Corticomotor Reorganization and Acute Pain Severity: A Randomized, Controlled Study Using Rapid Transcranial Magnetic Stimulation Mapping

OBJECTIVE

Although acute pain has been shown to reduce corticomotor excitability, it remains unknown whether this response resolves over time or is related to symptom severity. Furthermore, acute pain research has relied upon data acquired from the cranial "hotspot," which do not provide valuable information regarding reorganization, such as changes to the distribution of a painful muscle's representation within M1. Using a novel, rapid transcranial magnetic stimulation (TMS) mapping method, this study aimed to 1) explore the temporal profile and variability of corticomotor reorganization in response to acute pain and 2) determine whether individual patterns of corticomotor reorganization are associated with differences in pain, sensitivity, and somatosensory organization.

METHODS

Corticomotor (TMS maps), pain processing (pain intensity, pressure pain thresholds), and somatosensory (two-point discrimination, two-point estimation) outcomes were taken at baseline, immediately after injection (hypertonic [n = 20] or isotonic saline [n = 20]), and at pain resolution. Follow-up measures were recorded every 15 minutes until 90 minutes after injection.

RESULTS

Corticomotor reorganization persisted at least 90 minutes after pain resolution. Corticomotor depression was associated with lower pain intensity than was corticomotor facilitation (r = 0.47 [P = 0.04]). These effects were not related to somatosensory reorganization or peripheral sensitization mechanisms.

CONCLUSIONS

Individual patterns of corticomotor reorganization during acute pain appear to be related to symptom severity, with early corticomotor depression possibly reflecting a protective response. These findings hold important implications for the management and potential prevention of pain chronicity. However, further research is required to determine whether these adaptations relate to long-term outcomes in clinical populations.

Transcranial Direct Current Stimulation Accelerates The Onset of Exercise-Induced Hypoalgesia: A Randomized Controlled Study

Exercise-induced hypoalgesia (EIH) describes acute reductions in pain that occur following exercise. Current evidence suggests that the magnitude of EIH is small-to-moderate at best, warranting exploration of novel avenues to bolster these effects. Transcranial direct current stimulation (tDCS) has been shown to relieve pain and represents a promising intervention that may enhance EIH. This study aimed to determine whether anodal tDCS of the primary motor cortex (M1) can augment EIH in healthy individuals experiencing experimentally-induced musculoskeletal pain. Twenty-four healthy subjects attended 2 experimental sessions ("Day 0" and "Day 2"). On Day 0, subjects were injected with nerve growth factor into their right extensor carpi radialis brevis to induce persistent elbow pain. On Day 2, each subject received active or sham tDCS over M1 followed by an isometric grip exercise. Pain intensity, muscle soreness, sensitivity (pressure pain thresholds), and conditioned pain modulation were assessed prior to the nerve growth factor injection, on Day 2 before tDCS, immediately post-exercise, and 15 minutes post-exercise. Active tDCS expedited the onset of EIH, inducing immediate reductions in pain intensity that were not present until 15 minutes post-exercise in the sham group. However, active tDCS did not reduce muscle soreness or sensitivity when compared to sham tDCS. PERSPECTIVE: These findings suggest that active tDCS accelerates the onset of EIH in healthy individuals experiencing experimentally-induced pain. This may represent a promising means of enhancing adherence to exercise protocols. However, larger randomised controlled trials in persistent pain populations are required to confirm the clinical impact of these findings.

Corticomotor reorganization during short-term visuomotor training in the lower back: A randomized controlled study

INTRODUCTION

Accumulating evidence suggests that motor skill training is associated with structural and functional reorganization of the primary motor cortex. However, previous studies have focussed primarily upon the upper limb, and it is unclear whether comparable reorganization occurs following training of other regions, such as the lower back. Although this holds important implications for rehabilitation, no studies have examined corticomotor adaptations following short-term motor training in the lower back.

METHOD

The aims of this study were to (a) determine whether a short-term lumbopelvic tilt visuomotor task induced reorganization of the corticomotor representations of lower back muscles, (b) quantify the variability of corticomotor responses to motor training, and (c) determine whether any improvements in task performance were correlated with corticomotor reorganization. Participants were allocated randomly to perform a lumbopelvic tilt motor training task (n = 15) or a finger abduction control task involving no lumbopelvic movement (n = 15). Transcranial magnetic stimulation was used to map corticomotor representations of the lumbar erector spinae before, during, and after repeated performance of the allocated task.

RESULTS

No relationship between corticomotor reorganization and improved task performance was identified. Substantial variability was observed in terms of corticomotor responses to motor training, with approximately 50% of participants showing no corticomotor reorganization despite significant improvements in task performance.

CONCLUSION

These findings suggest that short-term improvements in lower back visuomotor task performance may be driven by changes in remote subcortical and/or spinal networks rather than adaptations in corticomotor pathways. However, further research using tasks of varying complexities and durations is required to confirm this hypothesis.

Cerebral peak alpha frequency reflects average pain severity in a human model of sustained, musculoskeletal pain

Heightened pain sensitivity, the amount of pain experienced in response to a noxious event, is a known risk factor for development of chronic pain. We have previously reported that pain-free, sensorimotor peak alpha frequency (PAF) is a reliable biomarker of pain sensitivity for thermal, prolonged pains lasting tens of minutes. To test whether PAF can provide information about pain sensitivity occurring over clinically relevant timescales (i.e., weeks), EEG was recorded before and while participants experienced a long-lasting pain model, repeated intramuscular injection of nerve growth factor (NGF), that produces progressively developing muscle pain for up to 21 days. We demonstrate that pain-free, sensorimotor PAF is negatively correlated with NGF pain sensitivity; increasingly slower PAF is associated with increasingly greater pain sensitivity. Furthermore, PAF remained stable following NGF injection, indicating that the presence of NGF pain for multiple weeks is not sufficient to induce the PAF slowing reported in chronic pain. In total, our results demonstrate that slower pain-free, sensorimotor PAF is associated with heightened sensitivity to a long-lasting musculoskeletal pain and also suggest that the apparent slowing of PAF in chronic pain may reflect predisease pain sensitivity.NEW & NOTEWORTHY Pain sensitivity, the intensity of pain experienced after injury, has been identified as an important risk factor in the development of chronic pain. Biomarkers of pain sensitivity have the potential to ease chronic pain burdens by preventing disease emergence. In the current study, we demonstrate that the speed of pain-free, sensorimotor peak alpha frequency recorded during resting-state EEG predicts pain sensitivity to a clinically-relevant, human model of prolonged pain that persists for weeks.

The influence of kinesiology tape colour on performance and corticomotor activity in healthy adults: a randomised crossover controlled trial

Background

There exists conflicting evidence regarding the impact of kinesiology tape on performance and muscle function. One variable that may account for disparities in the findings of previous studies is the colour of the tape applied. Colour is hypothesised to influence sporting performance through modulation of arousal and aggression. However, few studies have investigated the influence of colour on products designed specifically to enhance athletic performance. Further, no studies have investigated the potential influence of colour on other drivers of performance, such as corticomotor activity and neuromuscular function. Thus, the aim of this study was to investigate the influence of kinesiology tape colour on athletic performance, knee extensor torque, and quadriceps neuromuscular function.

Methods

Thirty two healthy participants were assessed under five conditions, applied in random order: (1) no kinesiology tape (control), (2) beige-coloured kinesiology tape applied with tension (sham A), (3) beige-coloured kinesiology tape applied with no tension (sham B), (4) red-coloured kinesiology tape applied with tension, and (5) blue-coloured kinesiology tape applied with tension. Athletic performance was assessed using a previously validated hop test, knee extensor torque was measured using an isokinetic dynamometer, and transcranial magnetic stimulation was utilised to provide insight into the neuromuscular functioning of the quadriceps musculature.

Results

Kinesiology tape had no beneficial impact on lower limb performance or muscle strength in healthy adults. The colour of the tape did not influence athletic performance (F (4, 120) = 0.593, p = 0.669), quadriceps strength (F (4, 120) = 0.787, p = 0.536), or neuromuscular function (rectus femoris: F (2.661, 79.827) = 1.237, p = 0.301).

Conclusion

This study found that kinesiology tape does not alter lower limb performance or muscle function in healthy adults, irrespective of the colour of the tape applied. Future research should seek to confirm these findings beyond the research setting, across a range of sports, and at a range of skill levels.

Trial registration

Australian New Zealand Clinical Trials Registry. ACTRN12616001506482. Prospectively registered on 01/11/2016.

The number of stimuli required to reliably assess corticomotor excitability and primary motor cortical representations using transcranial magnetic stimulation (TMS): a systematic review and meta-analysis

BACKGROUND

Transcranial magnetic stimulation (TMS) is a non-invasive means by which to assess the structure and function of the central nervous system. Current practices involve the administration of multiple stimuli over target areas of a participant's scalp. Decreasing the number of stimuli delivered during TMS assessments would improve time efficiency and decrease participant demand. However, doing so may also compromise the within- or between-session reliability of the technique. The aim of this review was therefore to determine the minimum number of TMS stimuli required to reliably measure (i) corticomotor excitability of a target muscle at a single cranial site and (ii) topography of the primary motor cortical representation of a target muscle across multiple cranial sites.

METHODS

Database searches were performed to identify diagnostic reliability studies published before May 2015. Two independent reviewers extracted data from studies employing single-pulse TMS to measure (i) the corticomotor excitability at a single cranial site or (ii) the topographic cortical organisation of a target muscle across a number of cranial sites. Outcome measures included motor evoked potential amplitude, map volume, number of active map sites and location of the map centre of gravity.

RESULTS

Only studies comparing the reliability of varying numbers of stimuli delivered to a single cranial site were identified. Five was the lowest number of stimuli that could be delivered to produce excellent within-session motor evoked potential (MEP) amplitude reliability (intraclass correlation coefficient (ICC) = 0.92, 95% CI 0.87 to 0.95). Ten stimuli were required to achieve consistent between-session MEP amplitudes among healthy participants (ICC = 0.89, 95% CI 0.76 to 0.95). However, between-session reliability was influenced by participant characteristics, intersession intervals and target musculature.

CONCLUSIONS

Further exploration of the reliability of multi-site TMS mapping is required. Five stimuli produce reliable MEP recordings during single-site TMS investigations involving one session. For single-site analyses involving multiple sessions, ten stimuli are recommended when investigating corticomotor excitability in healthy participants or the upper limb musculature. However, greater numbers of stimuli may be required for clinical populations or assessments involving the lower limb.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024579.

Hand therapy versus corticosteroid injections in the treatment of de Quervain's disease: A systematic review and meta-analysis

STUDY DESIGN

Systematic review with meta-analysis.

INTRODUCTION

Although corticosteroid injections are often cited as best practice in the treatment of de Quervain's disease, no reviews have compared their effectiveness to a multimodal definition of hand therapy.

PURPOSE

To compare the effectiveness of corticosteroid injections with that of i) hand therapy alone and ii) combined hand therapy/corticosteroid injection approaches in the treatment of de Quervain's disease.

METHODS

Searches of key databases were performed to identify experimental studies published between January 1950 and November 2014. Outcome measures included treatment success, pain, quality of life, and function.

RESULTS

Both corticosteroid injections and hand therapy improved pain and function from baseline, but between-group differences were not significant (across 6 studies). However, significantly more participants were treated successfully when combined orthosis/corticosteroid injection approaches were compared to i) orthoses (RR 0.53, 95% CI 0.35-0.80) and ii) injections alone (RR 0.76, 95% CI 0.64-0.89).

CONCLUSION

Combined orthosis/corticosteroid injection approaches are more effective than either intervention alone in the treatment of de Quervain's disease.

LEVEL OF EVIDENCE

1a.

Determining the number of stimuli required to reliably assess corticomotor excitability and primary motor cortical representations using transcranial magnetic stimulation (TMS): a protocol for a systematic review and meta-analysis

BACKGROUND

Transcranial magnetic stimulation (TMS) is a technique that can be used to assess corticospinal plasticity. Current TMS practices involve the administration of multiple stimuli over target areas of the participant's scalp. However, these procedures require 1 to 2 h per assessment. Decreasing the number of stimuli delivered during TMS assessments would improve time efficiency and decrease participant demand. Thus, the aim of this review is to determine the number of TMS stimuli required to reliably measure (1) corticomotor excitability to a target muscle at a single cranial site and (2) the topography of the primary motor cortical representation for a target muscle across multiple cranial sites (termed 'mapping').

METHODS/DESIGN

A systematic review and meta-analysis will be conducted. Electronic databases will be searched using pre-determined search terms to identify relevant studies and evaluate the studies for inclusion and risks of bias. Two independent reviewers will extract the data. Any disagreements will be resolved by a third reviewer. Studies employing single-pulse TMS to measure (1) corticomotor excitability at a single cranial site or (2) the topographic cortical organisation of a target muscle across a number of cranial sites, published before May 2015, will be included if they meet the eligibility criteria. Outcomes will include motor-evoked potential amplitude, map volume, number of active map sites, location of the map centre of gravity, and distance between the centres of gravity of the target muscle and one or more neighbouring muscles.

DISCUSSION

To our knowledge, this review will be the first to systematically explore the number of TMS stimuli required to reliably measure both corticomotor excitability and the topography of primary motor cortical representations. This research has the capacity to improve the efficiency of TMS, decrease participant demand, and facilitate the use of TMS as an outcome measurement tool in clinical populations.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015024579.