The association between dynamic balance and executive function: Which dynamic balance test has the strongest association with executive function? A systematic review and meta-analysis

AIM

The aging global population poses increasing challenges related to falls and dementia. Early identification of cognitive decline, particularly before noticeable symptoms manifest, is crucial for effective intervention. This review aims to determine the dynamic balance test most closely associated with executive function, potentially serving as a biomarker for cognitive decline.

RECENT FINDINGS

Based on recent reviews, inhibitory control, a component of executive function, holds significance in influencing balance performance. Studies suggest that the strength of the correlation between cognition and balance tends to be domain-specific and task-specific. Despite these findings, inconclusive evidence remains regarding the connection between executive function and various dynamic balance assessments. Our review identifies a significant association between all dynamic balance tests and executive function, albeit with varying strengths. Notably, a medium effect size is observed for the Timed Up and Go and Functional Reach Test, a small effect size for balance scales, and a strong effect size for postural sway. This review underscores a clear relationship between dynamic balance task performance and executive function. Dynamic posturography holds potential as a clinical biomarker for early detection of cognitive decline, with a note of caution due to observed heterogeneity and limited studies.

Site Dependency of Anodal Transcranial Direct-Current Stimulation on Reaction Time and Transfer of Learning during a Sequential Visual Isometric Pinch Task

Considering the advantages of brain stimulation techniques in detecting the role of different areas of the brain in human sensorimotor behaviors, we used anodal transcranial direct-current stimulation (a-tDCS) over three different brain sites of the frontoparietal cortex (FPC) in healthy participants to elucidate the role of these three brain areas of the FPC on reaction time (RT) during a sequential visual isometric pinch task (SVIPT). We also aimed to assess if the stimulation of these cortical sites affects the transfer of learning during SVIPT. A total of 48 right-handed healthy participants were randomly assigned to one of the four a-tDCS groups: (1) left primary motor cortex (M1), (2) left dorsolateral prefrontal cortex (DLPFC), (3) left posterior parietal cortex (PPC), and (4) sham. A-tDCS (0.3 mA, 20 min) was applied concurrently with the SVIPT, in which the participants precisely controlled their forces to reach seven different target forces from 10 to 40% of the maximum voluntary contraction (MVC) presented on a computer screen with the right dominant hand. Four test blocks were randomly performed at the baseline and 15 min after the intervention, including sequence and random blocks with either hand. Our results showed significant elongations in the ratio of RTs between the M1 and sham groups in the sequence blocks of both the right-trained and left-untrained hands. No significant differences were found between the DLPFC and sham groups and the PPC and sham groups in RT measurements within the SVIPT. Our findings suggest that RT improvement within implicit learning of an SVIPT is not mediated by single-session a-tDCS over M1, DLPFC, or PPC. Further research is needed to understand the optimal characteristics of tDCS and stimulation sites to modulate reaction time in a precision control task such as an SVIPT.

Different montages of transcranial direct current stimulation on postural stability in chronic low back pain patients: A randomized sham-controlled study

BACKGROUND

Impairment in both the motor and cognitive aspects of postural control is a critical issue in patients with chronic low back pain (CLBP) who experience high pain anxiety (HPA).

OBJECTIVE

This study aimed to compare the effects of cathodal and anodal transcranial direct current stimulation (c-tDCS and a-tDCS) over the dorsolateral prefrontal cortex (DLPFC) on postural control during cognitive postural tasks in CLBP patients with HPA.

METHODS

This study included 66 patients randomly assigned to three groups: DLPFC a-tDCS, DLPFC c-tDCS, and sham tDCS. All groups received 20 minutes of tDCS, but the stimulation was gradually turned off in the sham group. Postural stability indices were assessed using the Biodex Balance System.

RESULTS

Both the a-tDCS and c-tDCS groups showed a significant reduction in most postural stability indices at static and dynamic levels after the interventions (immediately, 24 hours, and one-week follow-up) during the cognitive postural task (P< 0.01). Additionally, there was a significant improvement in postural balance in the a-tDCS and c-tDCS groups compared to the sham tDCS group (P< 0.01). Furthermore, the a-tDCS group showed significantly greater improvement than the c-tDCS group (P< 0.01).

CONCLUSION

Based on the results, both a-tDCS and c-tDCS over the DLPFC had positive effects on postural control during cognitive postural tasks in CLBP patients with HPA.

The effect of transcranial direct current stimulation on rating of perceived exertion: A systematic review of the literature

The rating of perceived exertion (RPE) is a widely used method for monitoring the load during training, as it provides insight into the subjective intensity of effort experienced during exercises. Considering the role of brain in monitoring and perception of the effort, several studies explored the effect of transcranial direct current stimulation (tDCS) on RPE in different populations. The aim of current study is to review the studies that investigated the effect of tDCS on RPE in three groups including healthy untrained people, physically active persons, and athletes. Nine databases were searched for papers assessing the effect of tDCS on RPE. The data from the included studies were extracted and methodological quality was examined using the risk of bias 2 (ROB2) tool. Thirty-three studies met the inclusion criteria. According to the meta-analysis, active a-tDCS significantly decreased the RPE compared to the sham stimulation. The a-tDCS could decrease the RPE when it was applied over M1 or DLPF. Regarding the measurement tool, Borg's scale 6-20 and OMNI scale could show an improvement in RPE scale. A-tDCS is a promising technique that can decrease the RPE. M1 and DLPFC are suggested as the target area of stimulation. From the tools that measure the RPE, Borg's RPE 6-20 and OMNI scale could better show the effect of a-tDCS.

Transcranial pulsed current stimulation: A scoping review of the current literature on scope, nature, underlying mechanisms, and gaps

Transcranial pulsed current stimulation (tPCS) is a noninvasive brain stimulation technique that has aroused considerable attention in recent years. This review aims to provide an overview of the existing literature on tPCS, examine the scope and nature of previous research, investigate its underlying mechanisms, and identify gaps in the literature. Searching online databases resulted in 36 published tPCS studies from inception until May 2023. These studies were categorized into three groups: human studies on healthy individuals, human studies on clinical conditions, and animal studies. The findings suggest that tPCS has the potential to modulate brain excitability by entraining neural oscillations and utilizing stochastic resonance. However, the underlying mechanisms of tPCS are not yet fully understood and require further investigation. Furthermore, the included studies indicate that tPCS may have therapeutic potential for neurological diseases. However, before tPCS can be applied in clinical settings, a better understanding of its mechanisms is crucial. Hence, the tPCS studies were categorized into four types of research: basic, strategic, applied, and experimental research, to identify the nature of the literature and gaps. Analysis of these categories revealed that tPCS, with its diverse parameters, effects, and mechanisms, presents a wide range of research opportunities for future investigations.

Age and Type of Task-Based Impact of Mental Fatigue on Balance: Systematic Review and Meta-Analysis

The role of cognition in balance control suggests that mental fatigue may negatively affect balance. However, cognitive involvement in balance control varies with the type or difficulty of the balance task and age. Steady-state balance tasks, such as quiet standing, are well-learned tasks executed automatically through reflex activities controlled by the brainstem and spinal cord. In contrast, novel, and challenging balance tasks, such as proactively controlling balance while walking over rugged terrain or reacting to unexpected external perturbations, may require cognitive processing. Furthermore, individuals with preexisting balance impairments due to aging or pathology may rely on cognitive processes to control balance in most circumstances. This systematic review and meta-analysis investigated the effect of mental fatigue on different types of balance control tasks in young and older adults. A literature search was conducted in seven electronic databases and 12 studies met eligibility criteria. The results indicated that mental fatigue had a negative impact on both proactive (under increased cognitive load) and reactive balance in young adults. In older adults, mental fatigue affected steady-state and proactive balance. Therefore, mentally fatigued older individuals may be at increased risk of a loss of balance during steady-state balance task compared to their younger counterparts.

Exploring sensory, motor, and pain responses as potential side or therapeutic effects of sub-2 mA, 400 Hz transcranial pulsed current stimulation

BACKGROUND

Various brain stimulation devices capable of generating high-frequency currents are readily available. However, our comprehension of the potential side or therapeutic effects associated with high-frequency transcranial pulsed current stimulation (tPCS), particularly concerning the new 400 Hz tPCS device, AscenZ-IV Stimulator, developed by AscenZion Neuromodulation Co. Pte. Ltd. in Singapore, remains incomplete.

OBJECTIVE

This study examines preliminary parameters for the safe and comfortable application of 400 Hz tPCS at intensities below 2 mA.

METHODS

In a cross-sectional study, 45 healthy participants underwent sub-2 mA 400 Hz tPCS to assess sensory, motor, and pain thresholds on the dominant side. Study 1 (N = 15) targeted the primary motor cortex of the right-hand area, while study 2 (N = 30) focused on the back of the right forearm.

RESULTS

Study one showed that increasing the current intensity gradually resulted in no responses at sub-0.3 mA levels, but higher intensities (p < 0.001) induced sensory perception and pain responses. Study two replicated these findings and additionally induced motor responses along with the sensory and pain responses.

CONCLUSION

Despite the theoretical classification of tPCS as a subsensory level of stimulation, and the expectation that individuals receiving this type of current should not typically feel its application on the body, this high-frequency tPCS device generates different levels of stimulation due to the physiological phenomenon known as temporal summation. These novel levels of stimulation could be viewed as either potential "side-effects" of high frequency tPCS or as additional "therapeutic benefits". This dual capacity may position the device as one that generates both neuromodulatory and neurostimulatory currents. Comprehensive comprehension of this is vital for the development of therapeutic protocols that incorporate high-frequency tPCS.

The effects of anodal tDCS on pain reduction in people with knee osteoarthritis: A systematic review and meta-analysis

OBJECTIVES

To synthesise the literature on the efficacy of primary motor cortex anodal transcranial direct current stimulation (M1-a-tDCS), as a standalone or priming technique, for pain reduction in people with knee osteoarthritis (KOA).

METHODS

The systematic literature search was conducted in MEDLINE, CINAHL, Embase and CENTRAL according to PRISMA statement.

RESULTS

Fourteen studies involving 740 people with KOA were included. In the meta-analysis, six studies compared a-tDCS alone with sham stimulation, and five studies compared a-tDCS combined with other methods with sham stimulation. We found positive effect of a-tDCS alone on pain in KOA (standard mean difference (SMD) -0.52; 95% CI, -0.78 to -0.25; P=0.001; I2 = 69%). Further, a-tDCS with other treatments showed positive effect (SMD -1.23; 95% CI, -1.59 to -0.88; P<0.001; I2 = 48%) on pain in people with KOA. This evidence showed low certainty due to a high risk of bias and imprecision.

DISCUSSION AND CONCLUSION

A-tDCS could be considered as standalone and an adjunct treatment for pain reduction in people with KOA. Future randomised studies should address quality issues, including small sample size, to enhance the overall certainty of the findings.

SIGNIFICANCE

A-tDCS can be used as a standalone and adjunct treatment for KOA.

STUDY REGISTRATION

PROSPERO number CRD42021255114.

The Association Between Cognitive Domains and Postural Balance among Healthy Older Adults: A Systematic Review of Literature and Meta-Analysis

PURPOSE OF REVIEW

This review aims to explore which cognitive domain is more closely associated with which type of balance (static or dynamic).

RESENT FINDING

Based on recent reviews, inhibitory control, a part of cognition, plays a crucial role in balance performance. Previous reviews report significant links between cognition, mobility, and physical function in older adults. However, evidence regarding the relationship between cognition and balance scores remains inconclusive. The strength of association between cognition and balance appears to be domain-specific and task-specific. Executive function exhibits the strongest correlation with balance, while episodic memory shows a small link with dynamic balance. Processing speed and global cognition demonstrate moderate correlations. Additionally, there is a slight association between cognitive domains and static balance. Further research is needed to elucidate the underlying mechanisms and develop targeted interventions for managing balance-related concerns that are domain-specific and task-specific.

Does Multisession Cathodal Transcranial Direct Current Stimulation of the Left Dorsolateral Prefrontal Cortex Prime the Effects of Cognitive Behavioral Therapy on Fear of Pain, Fear of Movement, and Disability in Patients with Nonspecific Low Back Pain? A Randomized Clinical Trial Study

Many studies have shown that low back pain (LBP) is associated with psychosomatic symptoms which may lead to brain changes. This study aimed to investigate the effect of the concurrent application of cognitive behavioral therapy (CBT) and transcranial direct electrical stimulation (tDCS) over the left dorsolateral prefrontal cortex (DLPFC) on fear of pain, fear of movement, and disability in patients with nonspecific LBP. This study was performed on 45 LBP patients (23 women, 22 men; mean age 33.00 ± 1.77 years) in three groups: experimental (2 mA cathodal tDCS (c-tDCS)), sham (c-tDCS turned off after 30 s), and control (only received CBT). In all groups, CBT was conducted for 20 min per session, with two sessions per week for four weeks. Fear of pain, fear of movement, and disability were evaluated using questionnaires at baseline, immediately after, and one month after completion of interventions. Results indicated that all three different types of intervention could significantly reduce fear and disability immediately after intervention (p > 0.05). However, improvement in the experimental group was significantly higher than in the other groups immediately after and at the one-month follow-up after interventions (p < 0.05). DLPFC c-tDCS can prime the immediate effects of CBT and also the lasting effects on the reduction in the fear of pain, fear of movement, and disability in LBP patients.

Transcranial direct current stimulation over dorsolateral prefrontal cortex improves postural stability in non-specific chronic low back pain patients with high fear of pain: A randomized sham-controlled trial

Deficits in postural stability in response to environmental challenges are seen in chronic low back pain (CLBP) patients with high fear of pain (HFP). Hence, it is essential to follow effective approaches to treat postural stability deficits and improve the health status of these patients. The current study aimed to compare the effects of cathodal and anodal transcranial direct current stimulation (c-tDCS and a-tDCS) over the left dorsolateral prefrontal cortex (DLPFC) on postural stability in non-specific CLBP patients with HFP. In this randomized clinical trial study, 75 patients were randomly assigned to left DLPFC a-tDCS, left DLPFC c-tDCS and sham stimulation groups (n = 25 in each group). All groups received a single-session 2 mA tDCS for 20 min, but the stimulation was slowly turned off after 30 s in the sham group. Before, immediately, 24 h and 1 week after the interventions, postural stability indices were assessed using a Biodex Balance System. A significant reduction in most indices was shown in both a-tDCS and c-tDCS groups after interventions (immediately, 24 h and 1 week follow-up) during static and dynamic postural tasks compared with the sham tDCS group (p < .01). In addition, some tests showed a significant difference between a-tDCS and c-tDCS (p < .05). The findings indicated positive effects of both a-tDCS and c-tDCS on the left DLPFC, with more efficacy of a-tDCS on postural stability in LBP patients with HFP.

Concurrent multi-session anodal trans-cranial direct current stimulation enhances pelvic floor muscle training effectiveness for female patients with multiple sclerosis suffering from urinary incontinence and pelvic floor dysfunction: a randomized clinical trial study

INTRODUCTION AND HYPOTHESIS

Urinary incontinence following a pelvic floor muscle (PFM) dysfunction is a common disorder in women with multiple sclerosis (MS). Concurrent anodal transcranial direct current stimulation (a-tDCS) of the primary motor cortex (M1) may prime the effects of PFM training (PFMT) in MS patients. This study was aimed at investigating the effects of M1 a-tDCS on the effectiveness of PFMT in the treatment of female MS patients with urinary incontinence and PFM dysfunctions.

METHODS

In a randomized double-blinded, control trial study, 30 women with MS were divided into two groups (experimental group: concurrent active M1 a-tDCS and PFMT; control group: concurrent sham M1 a-tDCS and PFMT). Over the course of 8 weeks, these patients received 20-min interventions three times a week. As an indication of PFM function, the bladder base displacement was measured by ultrasonography before, during the 4th week, immediately, and 1 month after the intervention ended. Urinary incontinence was also measured by Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UISF) before, immediately, and 1 month after the intervention ended.

RESULTS

A significant improvement in PFM function occurred in the 4th week of intervention and remained 1 month after the intervention in the experimental group when compared with the control group (p<0.05). Compared with baseline, both groups reported significant improvements in PFM function at 8 weeks (p<0.05). Also, both groups were found to have decreased ICIQ-UIS scores after the intervention and at 1-month follow-up (p<0.05).

CONCLUSIONS

In MS patients, M1 a-tDCS can significantly enhance the effects of PFMT on the PFM function and urinary incontinence.

The Effect of Uni-Hemispheric Dual-Site Anodal tDCS on Brain Metabolic Changes in Stroke Patients: A Randomized Clinical Trial

Uni-hemispheric concurrent dual-site anodal transcranial direct current stimulation (UHCDS a-tDCS) of the primary motor cortex (M₁) and the dorsolateral prefrontal cortex (DLPFC) may enhance the efficacy of a-tDCS after stroke. However, the cellular and molecular mechanisms underlying its beneficial effects have not been defined. We aimed to investigate the effect of a-tDCS_M1-DLPFC on brain metabolite concentrations (N-acetyl aspartate (NAA), choline (Cho)) in stroke patients using magnetic resonance spectroscopy (MRS). In this double-blind, sham-controlled, randomized clinical trial (RCT), 18 patients with a first chronic stroke in the territory of the middle cerebral artery trunk were recruited. Patients were allocated to one of the following two groups: (1) Experimental 1, who received five consecutive sessions of a-tDCS_M1-DLPFC M₁ (active)-DLPFC (active). (2) Experimental 2, who received five consecutive sessions of a-tDCS_M1-DLPFC M1 (active)-DLPFC (sham). MRS assessments were performed before and 24 h after the last intervention. Results showed that after five sessions of a-tDCS_M1-DLPFC, there were no significant changes in NAA and Cho levels between groups (Cohen's d = 1.4, Cohen's d = 0.93). Thus, dual site a-tDCS_M1-DLPFC did not affect brain metabolites compared to single site a-tDCS M₁.

A step toward restoring hand functions in patients with multiple sclerosis-a study protocol

Multiple sclerosis (MS) is a chronic autoimmune disease characterized by inflammation, demyelination of axons, and oligodendrocyte loss in the central nervous system. This leads to neurological dysfunction, including hand impairment, which is prevalent among patients with MS. However, hand impairment is the least targeted area for neurorehabilitation studies. Therefore, this study proposes a novel approach to improve hand functions compared to current strategies. Studies have shown that learning new skills in the motor cortex (M1) can trigger the production of oligodendrocytes and myelin, which is a critical mechanism for neuroplasticity. Transcranial direct current stimulation (tDCS) has been used to enhance motor learning and function in human subjects. However, tDCS induces non-specific effects, and concurrent behavioral training has been found to optimize its benefits. Recent research indicates that applying tDCS during motor learning can have priming effects on the long-term potentiation mechanism and prolong the effects of motor training in health and disease. Therefore, this study aims to assess whether applying repeated tDCS during the learning of a new motor skill in M1 can be more effective in improving hand functions in patients with MS than current neurorehabilitation strategies. If this approach proves successful in improving hand functions in patients with MS, it could be adopted as a new approach to restore hand functions. Additionally, if the application of tDCS demonstrates an accumulative effect in improving hand functions in patients with MS, it could provide an adjunct intervention during rehabilitation for these patients. This study will contribute to the growing body of literature on the use of tDCS in neurorehabilitation and could have a significant impact on the quality of life of patients with MS.

Mental fatigue does not affect static balance under both single and dual task conditions in young adults

The ability to control balance and prevent falls while carrying out daily life activities may require a predominantly controlled (cognitive) or automatic processing depending on the balance challenge, age, or other factors. Consequently, this process may be affected by mental fatigue which has been shown to impair cognitive abilities. Controlling static balance in young adults is a relatively easy task that may proceed automatically with minimal cognitive input making it insusceptible to mental fatigue. To investigate this hypothesis, static single and dual task (while concurrently counting backward by seven) balance was assessed in 60 young adults (25.2 ± 2.4 years) before and after 45 min of Stroop task (mental fatigue condition) and watching documentary (control), presented in a randomized counterbalanced order on separate days. Moreover, because mental fatigue can occur due to task underload or overload, participants carried out two different Stroop tasks (i.e., all congruent, and mainly incongruent trials) on separate days in the mental fatigue condition. Results of the study revealed a significantly higher feeling of mental fatigue after the mental fatigue conditions compared to control (p < 0.001). Similarly, the performance on congruent Stroop trials decreases with time indicating objective mental fatigue (p < 0.01). However, there was no difference in balance or concurrent task performance under both single and dual task assessments between the three conditions (p  > 0.05) indicating lack of effect of mental fatigue on static balance in this population. Therefore, future studies investigating this phenomenon in occupational or sport settings in similar population should consider using more challenging balance tasks.

Neural mechanisms underlying state mental fatigue: a systematic review and activation likelihood estimation meta-analysis

Sustained performance of cognitive tasks could lead to the development of state mental fatigue characterized by subjective sensation of mental weariness and decrease in cognitive performance. In addition to the occupational hazards associated with mental fatigue, it can also affect physical performance reducing endurance, balance, and sport-specific technical skills. Similarly, mental fatigue is a common symptom in certain chronic health conditions such as multiple sclerosis affecting quality of life of the patients. Despite its widely acknowledged negative impact, the neural mechanisms underlining this phenomenon are still not fully understood. We conducted a systematic review and activation likelihood estimation (ALE) meta-analysis of functional neuroimaging studies investigating the effect of mental fatigue due to time-on-task (TOT) on brain activity to elucidate the possible underlying mechanisms. Studies were included if they examined change in brain activity induced by experimental mental fatigue (TOT effect) or investigated the relationship between brain activity and subjective mental fatigue due to TOT. A total of 33 studies met the review's inclusion criteria, 13 of which were included in meta-analyses. Results of the meta-analyses revealed a decrease in activity with TOT in brain areas that constitute the cognitive control network. Additionally, an increased activity with TOT, as well as negative relationship with subjective mental fatigue was found in parts of the default mode network of the brain. The changes in cognitive control and the default mode networks of the brain due to state mental fatigue observed in this study were discussed in relation to the existing theories of mental fatigue.

Feasibility of the A-STEP for the assessment of exercise capacity in people with cystic fibrosis

OBJECTIVES

To evaluate feasibility of the Alfred Step Test Exercise Protocol (A-STEP) for the assessment of exercise capacity in adults and children with cystic fibrosis (CF); in adults to test whether demographics and/or lung function correlated with exercise capacity.

METHODS

Adults and children with stable CF from two centres completed the A-STEP (a recently developed incremental maximal-effort step test). Feasibility was evaluated by: usefulness for exercise capacity assessment (measures of exercise capacity were: level reached, exercise-induced desaturation, and achievement of at least one maximal effort criteria); safety; operational factors; time to complete; floor and/or ceiling effects. We used multiple linear regression to test whether demographics and/or lung function correlated with exercise capacity.

RESULTS

A total of 49 participants: 38 adults (18 male), percent predicted (pp) forced expiration in one second (FEV₁ ) 29-109, aged 22-48 years and 11 children (6 male), ppFEV₁ 68-107, aged 10-15 years were included. Levels reached (mean (SD) [range]) were 10.2 (2.4) [6-15] (adults), 10.1 (2.5) [7-14] (children); desaturation (change between baseline and peak-exercise SpO₂ ): was 8.4 (3.8 [0-15]% (adults), 2.0 (2.0) [0-7]% (children). A total of 8 (21%) adults and no children desaturated <90% SpO₂ . At least one criterion for maximal effort was reached by 33 (84%) adults and 10 (91%) children. There were no adverse events. The A-STEP was straightforward to use and carried out by one operator. A total of 26 (68.4%) adults and 7 (63.6%) children completed the test within the recommended 8-12 min. All participants completed a minimum of 6 levels, and completed the test before the final 16th level. In adults, ppFEV₁ and ppFVC correlated with the level reached (r = 0.55; p = <0.001 and r = 0.66, p = <0.0001) and desaturation (r = 0.55, p = <0.001 and r = 0.45, p = <0.005).

CONCLUSION

In adults and children with stable CF, the A-STEP was feasible, safe, and operationally easy to use for the assessment of exercise capacity, without floor or ceiling effects. In adults, lung function correlated with exercise capacity.

Effect of Dietary-Based Lifestyle Modification Approaches on Anthropometric Indices and Dietary Intake Parameters in Women with Breast Cancer: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This systematic review and meta-analysis aimed to investigate the effect of dietary-based lifestyle modification interventions ("diet," or "diet + exercise," or "diet + exercise + behavioral" intervention) on the measures of anthropometric and dietary intake parameters in women with breas cancer (BC). Databases were searched until June 2021. Inclusion criteria were randomized controlled trials that enrolled only women with BC. Studies that used exercise or behavioral interventions alone were not included. Mean ± SD changes were extracted for each outcome, and pooled using a random-effects model; 7315 studies were identified. Fifty-one studies (n = 7743) were included. The median ± SD duration of treatment was 24 ± 16.65 wk. Dietary-based interventions significantly reduced body weight [45 studies (n = 7239), weighted mean difference (WMD) (95% CI): -2.6 (-3.2, -2.1) kg], BMI [31 studies (n = 5384); WMD (95% CI): -1.0 (-1.3, -0.7) kg/m2], lean body mass [15 studies (n = 1194); WMD (95% CI): -0.6(-0.7, -0.4) kg], fat mass [11 studies (n = 913); WMD (95% CI): -2.6 (-3.3, -1.8) kg], fat percentage [17 studies (n = 897); WMD (95% CI): -1.5 (-1.9, -1.3)%], hip circumference [9 studies (n = 489); WMD (95% CI): -2.43 (-3.34, -1.54) cm], and waist circumference [7 studies (n = 309); WMD (95% CI): 0.02 (-0.03, -0.005) cm]. Significant reductions in energy intakes [20 studies (n = 4608), WMD (95% CI): -162 (-220, 104) kcal/d] and fat intakes [7 studies (n = 4316), WMD (95% CI): -7.5 (-7.8, -7.2)% of energy/d], and an increase in fiber intakes [11 studies (n = 4241), WMD (95% CI): 2.4 (0.7, 4.1) g/d] were observed. No significant changes were seen in protein, carbohydrate, and fruit and vegetable intakes. Subgroup analyses showed that changes in anthropometric and dietary intake indices were significant in studies that enrolled patients with both obesity and normal weight, studies that used diet therapy in combination with exercise and behavioral therapy, and studies that started the intervention during the treatment period. Overall, a multimodal dietary-based lifestyle intervention had significant effects on anthropometric and dietary intake parameters in women with BC, specifically when started as early as the diagnosis. This meta-analysis was registered at PROSPERO as CRD42021291488.

Transcranial Direct Current Stimulation Enhances Exercise Performance: A Mini Review of the Underlying Mechanisms

Exercise performance (EP) is affected by a combination of factors including physical, physiological, and psychological factors. This includes factors such as peripheral, central, and mental fatigue, external peripheral factors such as pain and temperature, and psychological factors such as motivation and self-confidence. During the last century, numerous studies from different fields of research were carried out to improve EP by modifying these factors. During the last two decades, the focus of research has been mainly moved toward the brain as a dynamic ever-changing organ and the ways changes in this organ may lead to improvements in physical performance. Development of centrally-acting performance modifiers such as level of motivation or sleep deprivation and the emergence of novel non-invasive brain stimulation (NIBS) techniques such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS) are the key motives behind this move. This article includes three sections. Section Introduction provides an overview of the mechanisms behind the reduction of EP. The main focus of the Effects of tDCS on EP section is to provide a brief description of the effects of tDCS on maximal and submaximal types of exercise and finally, the section Mechanisms Behind the Effects of tDCS on EP provides description of the mechanisms behind the effects of tDCS on EP.

Mental Fatigue Impairs Postural Stability in Older Adults

Purpose: Postural instability can increase the risk of a fall in older adults. In this study, the impact of mental fatigue on postural stability among healthy older adults was investigated. Method: Participants were randomly divided into two groups: experimental and control groups. Postural stability of all participants was tested using the Biodex Balance System (BBS) before and immediately after watching a 30-min documentary program (control group) or completing a 30-min Stroop task (experimental group). Subjective ratings of mental fatigue were measured before and after the Stroop task or watching documentary program. Results: The results indicated that experimental group revealed higher stability scores in the posttest compared to pretest (P ≤ 0.001). However, there were no significant differences for BBS scores between pre and posttest in control group (P = .688). In addition, posttest of subjective ratings of mental fatigue was significantly different between experimental and control groups. Finally, there was also evidence of an association between Visual analog scale and BBS scores in the experimental group (rs = 0.712, P = .002). Conclusions: Mental fatigue caused by Stroop task had a negative impact on postural stability in older adults. This may be due to reduction in attentional resources that was caused by mental fatigue. Thus, mental fatigue could be considered as a risk factor for increased risk of falls in older adults.

Effect of cognitive task complexity on dual task postural stability: a systematic review and meta-analysis

The dual task experimental paradigm is used to probe the attentional requirements of postural control. However, findings of dual task postural studies have been inconsistent with many studies even reporting improvement in postural stability during dual tasking and thus raising questions about cognitive involvement in postural control. A U-shaped non-linear relationship has been hypothesized between cognitive task complexity and dual task postural stability suggesting that the inconsistent results might have arisen from the use of cognitive tasks of varying complexities. To systematically review experimental studies that compared the effect of simple and complex cognitive tasks on postural stability during dual tasking, we searched seven electronic databases for relevant studies published between 1980 to September 2020. 33 studies involving a total of 1068 participants met the review's inclusion criteria, 17 of which were included in meta-analysis (healthy young adults: 15 studies, 281 participants; Stroke patients: 2 studies, 52 participants). Narrative synthesis of the findings in studies involving healthy old adults was carried out. Our result suggests that in healthy population, cognitive task complexity may not determine whether postural stability increases or decreases during dual tasking (effect of cognitive task complexity was not statistically significant; P > 0.1), and thus the U-shaped non-linear hypothesis is not supported. Rather, differential effect of dual tasking on postural stability was observed mainly based on the age of the participants and postural task challenge, implying that the involvement of cognitive resources or higher cortical functions in the control of postural stability may largely depends on these two factors.

The effects of monophasic anodal transcranial pulsed current stimulation on corticospinal excitability and motor performance in healthy young adults: A randomized double-blind sham-controlled study

INTRODUCTION

Transcranial pulsed current stimulation (tPCS) could be used to deliver electrical pulses at different frequencies to entrain the cortical neurons of the brain. Frequency dependence of these pulses in the induction of changes in corticospinal excitability (CSE) has not been reported.

OBJECTIVE

We aimed to assess the effect of anodal tPCS (a-tPCS) at theta (4 Hz), and gamma (75 Hz) frequencies on CSE as assessed by the peak-to-peak amplitude of transcranial magnetic stimulation (TMS) induced motor evoked potentials (MEPs) and motor performance.

METHOD

In a randomized double-blinded sham-controlled cross over design study, seventeen healthy participants attended three experimental sessions and received either a-tPCS at 4 Hz, 75 Hz, or sham a-tPCS with 1.5 mA for 15 min. The amplitude of TMS induced resting MEPs and time for completion of the grooved pegboard test were recorded at baseline, immediately after, and 30-min after a-tPCS.

RESULTS

Both a-tPCS at 75 Hz and 4 Hz showed significantly increased CSE compared to sham. The a-tPCS at 75 Hz induced significantly higher CSE changes compared to 4 Hz. There was a significant increase in intracortical facilitation and a significant reduction in short-interval intra-cortical inhibition with both 4 and 75 Hz stimulation. However, the inhibition and facilitation did not correlate with CSE. Motor performance was unaffected by the interventions.

CONCLUSION

The high CSE changes in M1 in a-tPCS at 75 Hz provides an initial understanding of the frequency-specific effect of a-tPCS. More research is needed to establish this concept and to assess its behavioural relevance.

Development of the A-STEP: A new incremental maximal exercise capacity step test in cystic fibrosis

BACKGROUND

Exercise testing is important in people with cystic fibrosis (pwCF). The aim was to develop an incremental maximal step test to assess exercise capacity across the range of pwCF, without floor or ceiling effects, within restrictions of space, and infection prevention.

METHODS

The step test was developed in adults with stable CF. Subjects assisted in selecting: step height, start rate, increments, stage and test duration parameters. Equipment to externally pace and time the test and measure exercise parameters were selected. Reasons for stopping, criteria for achieving a maximal test, and key outcome measures were determined. Documentation to record and standardize the test and instructions to set up the metronome and timer App were developed. Infection control practices were considered.

RESULTS

Eight subjects were recruited to develop the Alfred Step Test Exercise Protocol (A-STEP) on a 20 cm portable step. The A-STEP package included a pretest information sheet, clinical assessment and instructions, recording worksheet, and the metronome/timer instructions. The test started at 18 steps/min. Each level increased by two steps/min to a maximum of 48 steps (Level 16). Results were presented as mean (SD) [range] for: age 30.63 (5.89) [21-39] years; FEV₁ 58.13 (18.33) [32-89]%; levels: 10.31 (3.29) [6-15.5]. The A-STEP required space of 2 m² and complied with current infection control guidelines.

CONCLUSIONS

The A-STEP is a new incremental maximal step test to assess exercise capacity in pwCF, without floor or ceiling effects. It addresses the issues of space restrictions and the need for strict infection prevention in the clinical setting.

Psychometric properties of the Persian version of the brief illness questionnaire in Iranian with non-specific chronic neck pain

INTRODUCTION

The Brief Illness Perception Questionnaire (BIPQ) is an instrument for assessing the illness perception. Illness perception varies between individuals based on their health status. There is no study that assess the psychometric properties of the Persian version of BIPQ in neck pain patients. The goal of this study was to evaluate the reliability, construct validity, and exploratory factor analysis of the Persian BIPQ in individuals with non-specific chronic neck pain.

METHODS

This is a cross-sectional study in which 123 individuals with non-specific chronic neck pain participated. 60 participants examined after 7 days for testing reliability. Reliability was assessed by intra-class correlation coefficient, standard error of measurement, and minimal detectable change. For assessing construct validity and item-total correlation, correlation tests were used. Also, exploratory factor analysis was done to assess the factor structure of the BIPQ.

RESULTS

Exploratory factor analysis' results showed that there were 2 factors with Eigenvalues >1. Factor 1 included "identity", "consequence", "timeline", and "emotional response". Factor 2 consisted of "coherence" and "treatment control". The intra-class correlation coefficient and the cronbach's alpha for the total score was 0.8 and 0.86 respectively. Results of correlation tests showed an acceptable construct validity except with SF-12 mental component. Item-total correlation tests demonstrated that the correlations were above 0.3 for all subscales except for "treatment control" and "coherence".

CONCLUSION

BIPQ has an acceptable properties to assess illness perception in individuals with non-specific chronic neck pain. The results of exploratory factor analysis and item-total correlation confirmed that 2-subscale version is more acceptable.

The Effect of a Single Session of Non-Invasive Brain Stimulation on Balance in Healthy Individuals: A Systematic Review and Best Evidence Synthesis

Aim: To evaluate the effects of a single session of non-invasive brain stimulation (NIBS) on postural balance. Introduction: The NIBS has been used widely in improving balance. However, the effect of a single session of NIBS on balance in healthy individuals has not been systemically reviewed. Methods: A systematic literature review and best evidence synthesis were conducted, according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines, to determine the effects of different NIBS techniques on balance function in healthy individuals. The methodological quality of included articles was assessed by the risk of bias, and the Downs and Black tool. Data were analyzed by using the best evidence synthesis. Thirty-five articles were included that used the following NIBS techniques: anodal transcranial direct current stimulation (a-tDCS), cathodal transcranial direct current stimulation (c-tDCS), continuous theta burst stimulation (cTBS), and repetitive transcranial magnetic stimulation (rTMS) on primary motor cortex (M1), supplementary motor area (SMA), dorsolateral prefrontal cortex (DLPFC), and cerebellum on balance. Results: Strong evidence showed that a-tDCS of M1, SMA improve balance in healthy participants, and the a-tDCS of DLPFC induces improvement only in dual task balance indices. Also, the findings indicate that cerebellar a-tDCS might significantly improve balance, if at least 10 min cerebellar a-tDCS with an intensity of ≥1 mA, over or maximum 1.5 cm below the inion, is used. Strong evidence showed that c-tDCS, cTBS, and rTMS are not effective on the balance. Conclusion: According to the results, the a-tDCS may be a useful technique to improve balance in healthy adults.

The effects of concurrent M1 anodal tDCS and physical therapy interventions on function of ankle muscles in patients with stroke: a randomized, double-blinded sham-controlled trial study

One of the most common symptoms in stroke patients is spasticity. The aims were to investigate the effects of anodal trans-cranial direct current stimulation (a-tDCS) over the affected primary motor cortex (M1) on ankle plantar flexor spasticity and dorsiflexor muscle activity in stroke patients. The design of this study was a randomized sham-controlled clinical trial. Thirty-two participants with stroke were randomly assigned to three groups (experimental, sham, control groups). Participants in the experimental and sham groups received 10-session 20-min M1 a-tDCS concurrent with physical therapy (PT), while the control group only received 10-session PT. All groups were instructed to perform home stretching exercises and balance training. Berg Balance Scale (BBS), Modified Ashworth Scale (MAS) of plantar flexors, and EMG activity of lateral gastrocnemius (LG) and tibialis anterior (TA) were recorded during active and passive ankle dorsiflexion immediately and 1 month after interventions. A significant reduction was shown in MAS and EMG activity of LG during dorsiflexion, immediately and 1 month after intervention in the M1 a-tDCS group (p <0.001). BBS also significantly increased only in the M1 a-tDCS group (p <0.001). In addition, EMG activity of TA during active dorsiflexion increased immediately and 1 month after intervention in the M1 a-tDCS group (p <0.001). However, in the sham and control groups, EMG activity of TA increased immediately (p<0.001), while this was not maintained 1 month after intervention (p >0.05). PT concurrent with M1 a-tDCS can significantly prime lasting effects of decreasing LG spasticity, increasing TA muscle activity, and also balance in stroke patients.

Transcranial Direct Current Stimulation Reduces the Negative Impact of Mental Fatigue on Swimming Performance

The issue of using transcranial direct current stimulation (tDCS) to improve sport performance has recently been a topic of interest for researchers. The purpose of this study was to examine the effect of tDCS over left dorsolateral prefrontal cortex (DLPFC) on mental fatigue and physical performance in professional swimmers. Fifteen professional swimmers were randomly assigned in a single-blinded, randomized, counterbalanced order to sham, anodal and cathodal stimulation conditions. Mental fatigue was induced by using a 60-min modified Stroop color-word task. Subjective ratings of mental fatigue were measured before and after the stroop task. The results showed that only anodal tDCS of the left DLPFC reduces adverse effects of mental fatigue in 50-meter swimming performance, whereas cathodal stimulation had no significant effect.

Investigating the sex-dependent effects of prefrontal cortex stimulation on response execution and inhibition

Context-dependent execution or inhibition of a response is an important aspect of executive control, which is impaired in neuropsychological and addiction disorders. Transcranial direct current stimulation (tDCS) of the dorsolateral prefrontal cortex (DLPFC) has been considered a remedial approach to address deficits in response control; however, considerable variability has been observed in tDCS effects. These variabilities might be related to contextual differences such as background visual-auditory stimuli or subjects' sex. In this study, we examined the interaction of two contextual factors, participants' sex and background acoustic stimuli, in modulating the effects of tDCS on response inhibition and execution. In a sham-controlled and cross-over (repeated-measure) design, 73 participants (37 females) performed a Stop-Signal Task in different background acoustic conditions before and after tDCS (anodal or sham) was applied over the DLPFC. Participants had to execute a speeded response in Go trials but inhibit their response in Stop trials. Participants' sex was fully counterbalanced across all experimental conditions (acoustic and tDCS). We found significant practice-related learning that appeared as changes in indices of response inhibition (stop-signal reaction time and percentage of successful inhibition) and action execution (response time and percentage correct). The tDCS and acoustic stimuli interactively influenced practice-related changes in response inhibition and these effects were uniformly seen in both males and females. However, the effects of tDCS on response execution (percentage of correct responses) were sex-dependent in that practice-related changes diminished in females but heightened in males. Our findings indicate that participants' sex influenced the effects of tDCS on the execution, but not inhibition, of responses.

The effect of omega-3 fatty acid supplementation on seizure frequency in individuals with epilepsy: a systematic review and meta-analysis

BACKGROUND

Although there is ample evidence for the effect of omega-3 supplementation on seizure frequency in individuals with epilepsy, the results are inconsistent. Therefore, we conducted this systematic review and meta-analysis to elucidate the potential effect of omega-3 supplementation in the adult and pediatric population.

METHODS

Clinical trials articles were searched in electronic databases (Web of Science, Scopus, PubMed/Medline, Embase, and Google Scholar database up to October 2020). No language limitation was imposed in the literature search. Moreover, gray literature search was done via searching the references of identified review papers to find more potentially relevant articles.

RESULTS

In order, the duration of the intervention and dosage of omega-3 fatty acid supplement of the included studies ranged from 12 to 42 weeks and 1000-2880 mg/day. Pooled results from the random-effects model indicated that seizure frequency following supplementation of omega-3 fatty acid decreased significantly (WMD: -6.15, 95% CI: -7.78, -4.53, P < 0.001). Furthermore, the results of the subgroup analysis revealed that seizure frequency was more alleviated in studies that used a daily dose of 1500 mg or less of omega-3 fatty acids as well as studies that had an intervention duration of more than 16 weeks. More importantly, our findings also showed that the effect of omega-3 intervention was greater in adults than in children with epilepsy.

CONCLUSION

The current meta-analysis on available trials suggested that omega-3 supplementation resulted in beneficial effects on seizure frequency in adult and children with epilepsy.

Pain Induced Changes in Brain Oxyhemoglobin: A Systematic Review and Meta-Analysis of Functional NIRS Studies

BACKGROUND

Neuroimaging studies show that nociceptive stimuli elicit responses in an extensive cortical network. Functional near-infrared spectroscopy (fNIRS) allows for functional assessment of changes in oxyhemoglobin (HbO), an indirect index for cortical activity. Unlike functional magnetic resonance imaging (fMRI), fNIRS is portable, relatively inexpensive, and allows subjects greater function. No systematic review or meta-analysis has drawn together the data from existing literature of fNIRS studies on the effects of experimental pain on oxyhemoglobin changes in the superficial areas of the brain.

OBJECTIVES

To investigate the effects of experimental pain on brain fNIRS measures in the prefrontal-cortex and the sensory-motor-area; to determine whether there is a difference in oxyhemodynamics between the prefrontal-cortex and sensory-motor-area during pain processing; to determine if there are differences in HbO between patients with centralized persistent pain and healthy controls.

METHODS

Studies that used fNIRS to record changes in oxyhemodynamics in prefrontal-cortex or sensory-motor-cortex in noxious and innoxious conditions were included. In total, 13 studies were included in the meta-analysis.

RESULTS

Pain has a significantly greater effect on pre-frontal-cortex and sensory-motor areas than nonpainful stimulation on oxyhemodynamics. The effect of pain on sensory-motor areas was greater than the effect of pain on the prefrontal-cortex. There was an effect of centralized pain in the CPP group on oxyhemodynamics from a noxious stimulus compared to control's response to pain.

CONCLUSIONS

Pain affects the prefrontal and sensory-motor cortices of the brain and can be measured using fNIRS. Implications of this study may lead to a simple and readily accessible objective measure of pain.

The Effects of Synbiotic Supplementation on Serum Anti-Inflammatory Factors in the Survivors of Breast Cancer with Lymphedema following a Low Calorie Diet: A Randomized, Double-Blind, Clinical Trial

BACKGROUND AND AIM

Breast cancer-related lymphedema (BCRL) is a treatment-related inflammatory complication in breast cancer survivors (BCSs). This study was aimed to evaluate the effect of synbiotic supplementation on serum concentrations of IL-10, TGF-β, VEGF, adiponectin, and edema volume among overweight or obese BCSs with lymphedema following a low-calorie diet (LCD).

METHOD

In a randomized double-blind, controlled clinical trial, 88 obese and overweight BCSs women were randomized to synbiotic supplement (n = 44) or placebo (n = 44) groups and both groups followed an LCD for 10 weeks. Pre- and post-intervention comparisons were made regarding the anti-inflammatory markers which included IL-10, TGF-β, VEGF, adiponectin, edema volume, and anthropometric measurements. Also, the same factors were analyzed to find inter-group disparities.

RESULTS

There were no significant differences among participants in the baseline, except for IL-10 and adiponectin. Post-intervention, no significant differences were observed regarding the anti-inflammatory markers, including IL-10, VEGF, adiponectin, and TGF-β between the groups. After 10 weeks of intervention edema volume significantly decreased in the synbiotic group; additionally, anthropometric measurements (body weight, BMI, body fat percent, and WC) decreased in both groups significantly (P < 0.001 and P < 0.005; respectively).

CONCLUSION

Synbiotic supplementation coupled with an LCD in a 10-week intervention had beneficial effects on increasing the serum TGF-β, IL-10, and adiponectin levels in women with BCRL. It also reduced arm lymphedema volume. Therefore, synbiotic supplementation can be effective in improving health status in BCRL patients.

Short-term research projects in cognitive neuroscience for undergraduate students: a contingency plan to maintain quality teaching during COVID-19 pandemic

The Corona Virus Disease 19 (COVID-19) pandemic has imposed serious restrictions for academic institutions to maintain their research and teaching practical subjects. Universities have implemented adaptive measures to maintain educational activities and achieve the learning objectives for undergraduate and postgraduate students by shifting to online teaching and learning. Although such approaches have enabled delivering the theoretical content of courses during the pandemic, universities have faced serious difficulties in running practicals with actual research experiments and teaching hand-on skills because such activities potentially override the required safety guidelines. Here, we report an adaptive measure, implemented at Monash University, to run home-based studies in cognitive neuroscience and achieve learning objectives, which are normally delivered in face-to-face practicals. We introduce two specifically designed short-term research projects and describe how different aspects of these projects, such as tutorials, experiments, and assessments, were modified to meet the required social distancing. The results of cognitive tests were closely comparable between the laboratory-based and home-based experiments indicating that students followed the guidelines and the required procedures for a reliable data collection. Our assessments of students' performance and feedback indicate that the majority of our educational goals were achieved, while all safety guidelines and distancing requirements were also met.

Is Ankle Plantar Flexor Strength Associated With Balance and Walking Speed in Healthy People? A Systematic Review and Meta-Analysis

OBJECTIVE

The purpose of this study was to investigate the association between ankle plantar flexor muscle (PF) strength and balance and walking speed in healthy adults.

METHODS

Four databases (Ovid MEDLINE, Ovid EMBASE, CINAHL Plus, and SPORTDiscus) were searched from inception to December 2019. Studies with any design were included if the association between PF strength and balance and walking speed was investigated among healthy adults. Articles were screened for eligibility independently by 2 reviewers. Study characteristics and Pearson r values derived from the association between PF strength and balance and walking speed were extracted. Thirty-four studies were eligible. The main group of interest in the studies was older adults. Pearson r values were transformed to rz values using Fisher z-transformation. Meta-analysis of rz values was conducted and then back-transformed to r.

RESULTS

In older adults, PF maximal isometric strength had a positive weak association with static balance (r = 0.20; 95% CI = 0.08-0.32), a positive moderate association with dynamic reactive balance (r = 0.42; 95% CI = 0.32-0.57) and proactive balance (r = 0.55; 95% CI = 0.18-1.06), and a positive weak association with preferred walking speed (r = 0.29; 95% CI = 0.19-0.41) and maximum walking speed (r = 0.34; 95% CI = 0.06-0.63). In younger adults, there was a moderate association between early-phase PF rate of torque development and reactive balance (0.42 < r < 0.52).

CONCLUSIONS

PF strength appears to be moderately associated with dynamic reactive and proactive balance and weakly associated with static balance and walking speed. This finding highlights the potential role of PF strength in dynamic reactive and proactive balance.

IMPACT

This meta-analysis showed that ankle PF strength might be important for challenging dynamic balance tasks.

Unilateral Strength Training of the Less Affected Hand Improves Cortical Excitability and Clinical Outcomes in Patients With Subacute Stroke: A Randomized Controlled Trial

OBJECTIVES

To investigate whether unilateral strength training helps improve cortical excitability and clinical outcomes after stroke.

DESIGN

Randomized controlled trial.

SETTING

Rehabilitation sciences research center.

PARTICIPANTS

Patients with subacute stroke (N=26) were randomly assigned to a control group (n=13) or the experimental group (n=13).

INTERVENTIONS

Participants in both groups received conventional physiotherapy. The experimental group also received unilateral strength training of the less affected wrist extensors. Interventions were applied for 4 weeks (12 sessions, 3 d/wk).

MAIN OUTCOME MEASURES

Cortical excitability in both the ipsilesional hemisphere (ipsiH) and contralesional hemisphere (contraH) was assessed by measuring resting motor threshold (RMT), active motor threshold (AMT), motor evoked potential (MEP), and cortical silent period (CSP) at baseline and after the 4-week intervention period. Clinical outcomes were obtained by evaluating wrist extension strength in both the more affected and less affected hands, upper extremity motor function, activities of daily living (ADL), and spasticity.

RESULTS

The experimental group showed greater MEP amplitude (P=.001) in the ipsiH and shorter CSP duration in both the ipsiH (P=.042) and contraH (P=.038) compared with the control group. However, the reductions in RMT and AMT in both hemispheres were not significantly different between groups. Improvements in wrist extension strength in the more affected (P=.029) and less affected (P=.001) hand, upper extremity motor function (P=.04), and spasticity (P=.014) were greater in the experimental group. No significant difference in ADLs was detected between groups.

CONCLUSIONS

A combination of unilateral strength training and conventional physiotherapy appears to be a beneficial therapeutic modality for improving cortical excitability and some clinical outcomes in patients with stroke.

Genetic Polymorphisms Do Not Predict Interindividual Variability to Cathodal Transcranial Direct Current Stimulation of the Primary Motor Cortex

Introduction: High variability between individuals (i.e., interindividual variability) in response to transcranial direct current stimulation (tDCS) has become a commonly reported issue in the tDCS literature in recent years. Inherent genetic differences between individuals have been proposed as a contributing factor to observed response variability. This study investigated whether tDCS interindividual variability was genetically mediated. Methods: A large sample size of 61 healthy males received cathodal tDCS (c-tDCS) and sham-tDCS of the primary motor cortex at 1 mA and 10 min via 6 × 4 cm active and 7 × 5 cm return electrodes. Corticospinal excitability (CSE) was assessed via 25 single-pulse transcranial magnetic stimulation motor-evoked potentials (MEPs). Intracortical inhibition was assessed via twenty-five 3 msec interstimulus interval (ISI) paired-pulse MEPs, known as short-interval intracortical inhibition (SICI). Intracortical facilitation (ICF) was assessed via twenty-five 10 msec ISI paired-pulse MEPs. Gene variants encoding for excitatory and inhibitory neuroreceptors were determined via saliva samples. Predetermined thresholds and statistical cluster analyses were used to subgroup individuals. Results: Two distinct subgroups were identified, "responders" reducing CSE following c-tDCS and "nonresponders" showing no reduction or even increase in CSE. Differences in CSE between responders and nonresponders following c-tDCS were not explained by changes in SICI or ICF. Conclusions: No significant relationships were reported between gene variants and interindividual variability to c-tDCS, suggesting that the chosen gene variants did not influence the activity of the neuroreceptors involved in eliciting changes in CSE in responders following c-tDCS. In this largest c-tDCS study of its kind, novel insights were reported into the contribution genetic factors may play in observed interindividual variability to c-tDCS. Impact statement This study adds insight into the issue of interindividual variability to c-tDCS. It highlights not all individuals respond to c-tDCS similarly when exposed to the same stimulus parameters. This disparity in response to c-tDCS between individuals does not appear to be genetically mediated. For c-tDCS to progress to large-scale clinical application, reliability, predictability and reproducibility are essential. Systematically investigating factors contributing to interindividual variability take steps towards this progress the c-tDCS field towards the potential development of screening tools to determine clinical suitability to c-tDCS to ensure its application in those who may benefit the most.

The effects of a single-session cathodal transcranial pulsed current stimulation on corticospinal excitability: A randomized sham-controlled double-blinded study

Transcranial pulsed current stimulation (tPCS) of the human motor cortex has received much attention in recent years. Although the effect of anodal tPCS with different frequencies has been investigated, the effect of cathodal tPCS (c-tPCS) has not been explored yet. Therefore, the aim of the present study was to investigate the effect of c-tPCS at 4 and 75 Hz frequencies on corticospinal excitability (CSE) and motor performance. In a randomized sham-controlled crossover design, fifteen healthy participants attended three experimental sessions and received either c-tPCS at 75 Hz, 4 Hz or sham with 1.5 mA for 15 min. Transcranial magnetic stimulation and grooved pegboard test were performed before, immediately after and 30 min after the completion of stimulation at rest. The findings indicate that c-tPCS at both 4 and 75 Hz significantly increased CSE compared to sham. Both c-tPCS at 75 and 4 Hz showed a significant increase in intracortical facilitation compared to sham, whereas the effect on short-interval intracortical inhibition was not significant. The c-tPCS at 4 Hz but not 75 Hz induced modulation of intracortical facilitation correlated with the CSE. Motor performance did not show any significant changes. These results suggest that, compared with sham stimulation, c-tPCS at both 4 and 75 Hz induces an increase in CSE.

Does anodal trans-cranial direct current stimulation of the damaged primary motor cortex affects wrist flexor muscle spasticity and also activity of the wrist flexor and extensor muscles in patients with stroke?: a Randomized Clinical Trial

Spasticity is a common symptom in stroke survivors. This study is double-blinded, sham-controlled randomized, clinical trial with three parallel arms. The aim of the study was to investigate the effects of anodal trans-cranial direct current stimulation (a-tDCS) over the damaged primary motor cortex (M1) on spasticity of the wrist flexor and also the activity of wrist flexor and extensor muscles in sub-acute stroke patients. This study was performed on 32 stroke patients. The patients are assigned to three groups (intervention, sham, and control). All participants in the first two groups received 20-min concurrent M1 a-tDCS or sham tDCS and functional electrical stimulation (FES) for 10 sessions (5 sessions per week), while participants in control group were given only 20-min FES for 10 sessions. Modified Ashworth scale of wrist flexors and also electromyography (EMG) activity of flexor carpi radialis (FCR) and extensor carpi radialis (ECR) were recorded before, immediately, and 1 month after the interventions. A significant reduction was shown in the MAS and EMG activity of FCR muscle at passive rest position of the wrist, immediately and 1 month after the intervention in M1 a-tDCS compared to sham and control groups (p < 0.001). Also, the EMG activity of FCR and ECR muscles during active wrist flexion and extension increased immediately and 1 month after intervention in M1 a-tDCS compared to the other groups, respectively (p < 0.001). M1 a-tDCS can significantly decrease the spasticity of wrist flexor muscle and also increase the wrist flexor and extensor muscles activity in stroke patients during active flexion and extension.

Can genetic polymorphisms predict response variability to anodal transcranial direct current stimulation of the primary motor cortex?

Genetic mediation of cortical plasticity and the role genetic variants play in previously observed response variability to transcranial direct current stimulation (tDCS) have become important issues in the tDCS literature in recent years. This study investigated whether inter-individual variability to tDCS was in-part genetically mediated. In 61 healthy males, anodal-tDCS (a-tDCS) and sham-tDCS were administered to the primary motor cortex at 1 mA for 10-min via 6 × 4 cm active and 7 × 5 cm return electrodes. Twenty-five single-pulse transcranial magnetic stimulation (TMS) motor evoked potentials (MEP) were recorded to represent corticospinal excitability (CSE). Twenty-five paired-pulse MEPs were recorded with 3 ms inter-stimulus interval (ISI) to assess intracortical inhibition (ICI) via short-interval intracranial inhibition (SICI) and 10 ms ISI for intracortical facilitation (ICF). Saliva samples were tested for specific genetic polymorphisms in genes encoding for excitatory and inhibitory neuroreceptors. Individuals were sub-grouped based on a pre-determined threshold and via statistical cluster analysis. Two distinct subgroups were identified, increases in CSE following a-tDCS (i.e. Responders) and no increase or even reductions in CSE (i.e. Non-responders). No changes in ICI or ICF were reported. No relationships were reported between genetic polymorphisms in excitatory receptor genes and a-tDCS responders. An association was reported between a-tDCS responders and GABRA3 gene polymorphisms encoding for GABA-A receptors suggesting potential relationships between GABA-A receptor variations and capacity to undergo tDCS-induced cortical plasticity. In the largest tDCS study of its kind, this study presents an important step forward in determining the contribution genetic factors play in previously observed inter-individual variability to tDCS.

A Checklist to Reduce Response Variability in Studies Using Transcranial Magnetic Stimulation for Assessment of Corticospinal Excitability: A Systematic Review of the Literature

Response variability between individuals (interindividual variability) and within individuals (intraindividual variability) is an important issue in the transcranial magnetic stimulation (TMS) literature. This has raised questions of the validity of TMS to assess changes in corticospinal excitability (CSE) in a predictable and reliable manner. Several participant-specific factors contribute to this observed response variability with a current lack of consensus on the degree each factor contributes. This highlights a need for consistency and structure in reporting study designs and methodologies. Currently, there is no summarized review of the participant-specific factors that can be controlled and may contribute to response variability. This systematic review aimed to develop a checklist of methodological measures taken by previously published research to increase the homogeneity of participant selection criteria, preparation of participants before experimental testing, participant scheduling, and the instructions given to participants throughout experimental testing to minimize their effect on response variability. Seven databases were searched in full. Studies were included if CSE was measured via TMS and included methodological measures to increase the homogeneity of the participants. Eighty-four studies were included. Twenty-three included measures to increase participant selection homogeneity, 21 included measures to increase participant preparation homogeneity, while 61 included measures to increase participant scheduling and instructions during experimental testing homogeneity. These methodological measures were summarized into a user-friendly checklist with considerations, suggestions, and rationale/justification for their inclusion. This may provide the framework for further insights into ways to reduce response variability in TMS research.

Determination of anodal tDCS intensity threshold for reversal of corticospinal excitability: an investigation for induction of counter-regulatory mechanisms

Transcranial direct current stimulation is applied to modulate activity, and excitability of the brain. Basically, LTP-like plasticity is induced when anodal tDCS (a-tDCS) is applied over the primary motor cortex. However, it has been shown that specific parameters of a-tDCS can induce a plasticity reversal. We aimed to systematically assess the intensity threshold for reversal of the direction of plasticity induced by a-tDCS, monitored by corticospinal excitability (CSE), and explored mechanisms regulating this reversal. Fifteen healthy participants received a-tDCS in pseudo-random order for 26 min with four intensities of 0.3, 0.7, 1, and 1.5 mA. To measure CSE changes, single-pulse TMS was applied over the left M1, and motor evoked potentials of a contralateral hand muscle were recorded prior to a-tDCS, immediately and 30-min post-intervention. Paired-pulse TMS was used to evaluate intracortical excitation and inhibition. CSE increased significantly following a-tDCS with an intensity of 0.7 mA; however, the expected effect decreased and even reversed at intensities of 1 and 1.5 mA. ICF was significantly increased while SICI and LICI decreased at 0.7 mA. On the other hand, a significant decrease of ICF, but SICI and LICI enhancement was observed at intensities of 1, and 1.5 mA. The present findings show an intensity threshold of ≥ 1 mA for 26 min a-tDCS to reverse LTP- into LTD-like plasticity. It is suggested that increasing stimulation intensity, with constant stimulation duration, activates counter-regulatory mechanisms to prevent excessive brain excitation. Therefore, stimulation intensity and plasticity induced by a-tDCS might non-linearly correlate in scenarios with prolonged stimulation duration.

The Effect of Transcranial Pulsed Current Stimulation at 4 and 75 Hz on Electroencephalography Theta and High Gamma Band Power: A Pilot Study

Introduction: Transcranial pulsed current stimulation (tPCS) is an emerging noninvasive brain stimulation technique that has shown significant effects on cortical excitability. To date, electrophysiological measures of the efficiency of monophasic tPCS have not been reported. Objective: We aimed to explore the effects of monophasic anodal and cathodal-tPCS (a-tPCS/c-tPCS) at theta (4 Hz) and gamma (75 Hz) frequencies on theta and high gamma electroencephalography (EEG) oscillatory power. Methods: In a single-blind, randomized, sham-controlled crossover design, 15 healthy participants were randomly assigned into 5 experimental sessions in which they received a-PCS/c-tPCS at 4 and 75 Hz or sham stimulation over the left primary motor cortex (M1) for 15 min at an intensity of 1.5 mA. Changes in theta and high gamma oscillatory power were recorded at baseline, immediately after, and 30 min after stimulation using EEG at rest with eyes open. Results: a-tPCS at 4 Hz showed a significant increase in theta power compared with sham, whereas c-tPCS at 4 Hz had no significant effect on theta power. a-tPCS at 75 Hz produced no changes in high gamma power compared with sham. Importantly, c-tPCS at 75 Hz led to a significant reduction in high gamma power compared with baseline, as well as compared with c-tPCS at 4 Hz and sham stimulation. Conclusion: The results demonstrate the modulation of oscillatory brain activity by monophasic tPCS, and highlight the need for future studies on a larger scale to confirm these initial findings. Impact statement Transcranial pulsed current stimulation (tPCS) is a novel brain stimulation technique. Recently, tPCS has been introduced to directly modulate brain oscillations by applying pulsatile current over the target brain area. Using both anodal and cathodal monophasic tPCS at theta and gamma frequencies, we demonstrate the ability of the stimulation to modulate brain activity. The present findings are the first direct electroencephalography evidence of an interaction between tPCS and ongoing oscillatory activity in the human motor cortex. Our work recommends tPCS as a tool for investigating human brain oscillations and open more studies in this area.

Test-retest reliability and responsiveness of isokinetic dynamometry to assess wrist flexor muscle spasticity in subacute post-stroke hemiparesis

INTRODUCTION

To overcome the limitations of clinical scales, objective measurement methods are becoming prominent in spasticity assessment. The aim of this study was to assess the test-retest reliability and responsiveness of isokinetic dynamometry to evaluate wrist flexor spasticity in patients with subacute stroke.

METHODS

Twenty six patients with hemiparetic stroke (13 men, 13 women, mean age 51.38 ± 12.64 years) volunteered to take part in this study. Resistive torque in the wrist flexor muscles was measured twice, 1 day apart, with an isokinetic dynamometer. Wrist extension was tested at four speeds (5, 60, 120 and 180°/s). Torque response at the lowest speed (5°/s) was attributed to the non-neural component of the wrist flexor muscles, and was subtracted from the torque response at the higher speeds to calculate reflex torque (spasticity). The reliability of reflex torque measurements at 60, 120 and 180°/s was evaluated with the intraclass correlation coefficient (ICC_2,1) and standard error of measurement (SEM and SEM%), which reflect reproducibility and measurement error, respectively. Responsiveness was calculated as the smallest real difference (SRD and SRD%).

RESULTS

Reproducibility was excellent at different movement speeds (ICC_{2, 1} 0.76-0.85). SEM% ranged from 11% to 21%, and SRD% ranged from 30% to 58%. ICC values increased, and SEM% and SRD% decreased, as test speed increased.

CONCLUSION

Our results support the reliability and responsiveness of isokinetic dynamometry to quantify spasticity in wrist flexor muscles in patients with subacute stroke. Reliability and responsiveness increased as the speed of wrist movement increased.

The effects of transcranial direct current stimulation on corticospinal and cortico-cortical excitability and response variability: Conventional versus high-definition montages

Response variability following transcranial direct current stimulation (tDCS) highlights need for exploring different tDCS electrode montages. Corticospinal excitability (CSE), cortico-cortical excitability and intra-individual variability was compared following conventional and high-definition (HD) anodal (a-tDCS) and cathodal (c-tDCS) tDCS. Fifteen healthy males attended four sessions at-least one-week apart: conventional a-tDCS, conventional c-tDCS, HD-a-tDCS, HD-c-tDCS. TDCS was administered (1 mA, 10-minutes) over primary motor cortex (M1), via 6 × 4 cm active and 7 × 5 cm return electrodes (conventional tDCS) and 4 × 1 ring-electrodes 3.5 cm apart over M1 (HD-tDCS). For CSE, twenty-five single-pulse transcranial magnetic stimulation (TMS) peak-to-peak motor evoked potentials (MEP) were recorded at baseline, 0-minutes and 30-minutes post-tDCS. Twenty-five paired-pulse MEPs with 3-millisecond (ms) inter-pulse interval (IPI) and twenty-five at 10 ms assessed short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). MEP standardised z-values standard deviations represented intra-individual variability. No significant changes in CSE from baseline were reported for all four interventions. No significant differences were reported in CSE between conventional and HD a-tDCS, but significant differences between conventional and HD c-tDCS 0-minutes post-tDCS. Conventional tDCS significantly reduced intra-individual variability compared to HD-tDCS for a-tDCS (0-minutes) and c-tDCS (30-minutes). No changes were reported for SICI/ICF. These novel findings of increased intra-individual variability following HD-tDCS, at the current stimulus parameters, highlight need for further nuanced research and refinement to optimise the HD-tDCS dosage-response relationship.

Longer Transcranial Magnetic Stimulation Intertrial Interval Increases Size, Reduces Variability, and Improves the Reliability of Motor Evoked Potentials

High rates of variability in the amplitude of transcranial magnetic stimulation (TMS)-induced motor evoked potentials (MEPs), a popular method for assessing corticospinal excitability (CSE), make it essential to examine inherent reliability of the MEP amplitude. We aimed to investigate the effects of different intertrial intervals (ITIs) of single-pulse TMS on the amplitude, variability, and test-retest reliability of MEPs. Twenty-five TMS single pulses were recorded at four different ITIs of 5, 10, 15, and 20 sec from 15 healthy participants who attended two experimental sessions. Repeated measures analysis of variance (rmANOVA) and standardized z-value standard deviations (SDs) were used to investigate the effects of ITIs on MEP amplitudes and variability. Test-retest reliability of MEP amplitudes was also assessed using rmANOVA and intraclass correlation (ICC). rmANOVA revealed significantly larger MEP amplitudes following ITIs of 10, 15, and 20 sec compared with ITI 5, with no significant increases between ITIs of 15 and 20 sec. Standardized z-value SDs revealed variability rate reduction following longer ITIs with significant reductions occurring following ITIs of 10, 15, and 20 sec compared with ITI 5 with no significant difference between ITIs of 15 and 20 sec. rmANOVA showed no significant Time main effect on the MEP changes confirming within- and between-session agreement. ICCs reported significant within- and between-session reliability in all selected ITIs. The findings of the current study indicate that longer ITIs up to 15 sec can significantly induce larger MEPs with lower variability and higher reliability. The increase in ITIs not only reduces the chance of TMS-induced changes in CSE but also helps us to use this assessment tool in studies with smaller sample sizes.

Comparing the effects of multi-session anodal trans-cranial direct current stimulation of primary motor and dorsolateral prefrontal cortices on fatigue and quality of life in patients with multiple sclerosis: a double-blind, randomized, sham-controlled trial

OBJECTIVE

To compare the effects of anodal trans-cranial direct current stimulation (a-tDCS) over primary motor and dorsolateral prefrontal cortices on Fatigue Severity Scale and its lasting effect on fatigue reduction and improvement in quality of life in patients with multiple sclerosis.

DESIGN

A randomized, double-blinded, sham-controlled parallel clinical trial study.

SETTING

Neurological physiotherapy clinics.

SUBJECTS

Thirty-nine participants were randomly assigned to three groups: dorsolateral prefrontal cortex a-tDCS, primary motor a-tDCS (experimental groups) and sham a-tDCS. Finally, 36 participants completed the whole study (n = 12 in each group).

INTERVENTIONS

Participants in the experimental groups received six-session a-tDCS (1.5 mA, 20 minutes) during two weeks (three sessions per week). The sham group received six sessions of 20-minute sham stimulation.

MAIN MEASURES

The Fatigue Severity Scale and quality of life were assessed before, immediately and four weeks after the intervention.

RESULTS

Findings indicated a significant reduction in the Fatigue Severity Scale and a significant increase in the quality of life in both experimental groups, immediately after the intervention (P < 0.001), while Fatigue Severity Scale and quality of life changes were not significant in the sham a-tDCS group (P > 0.05). In addition, improvement of the variables remained four weeks after the intervention in dorsolateral prefrontal cortex a-tDCS (mean differences (95% confidence interval): 0.03 (-0.63 to 0.68) as compared to primary motor (-0.62 (-0.11 to -1.14) and sham a-tDCS groups (-0.47 (-1.37 to 0.43)).

CONCLUSION

Both primary motor and dorsolateral prefrontal cortex a-tDCS as compared to sham intervention can immediately improve fatigue and quality of life. However, the effects last up to four weeks only by the dorsolateral prefrontal cortex a-tDCS.

The effects of consecutive sessions of anodal transcranial direct current stimulation over the primary motor cortex on hand function in healthy older adults

BACKGROUND

With advancing age, changes in the central nervous system may lead to motor functional deficits. Non-invasive brain stimulation techniques are suggested to help modifying brain function.

OBJECTIVES

The aim of the current study was to investigate the effect of using multi session anodal transcranial Direct Current Stimulation (a-tDCS) over the primary motor cortex (M1) on the hand function in healthy older adults.

METHOD

In this randomized, double-blinded, sham-controlled study 32 participants received active or sham a-tDCS (1 mA, 20 min, for five consecutive days) and performed the Purdue Pegboard Test (PPT) on the first day before tDCS application, immediately (T1), 30 min (T2), and one week after the last session (5th day) (T3) of the stimulation.

RESULTS

There was a significant improvement for PPT (p < 0.05) in a-tDCS group at all post-test values except for PPT for left hand (PPTL) at T1. Compared to the sham group, the results indicated significant improvement in all PPT subtests (P < 0.05), except for PPTL at T1, PPT for both hands at T2 and PPT assembly at T3 in a-tDCS group.

CONCLUSION

The current findings suggest a-tDCS can be considered as a promising stand-alone technique in the intervention of the age-related decline of manual dexterity for improving hand function.