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Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis
Journal of Bodywork & Movement Therapies xxx (xxxx) xxx
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Mentored Research: Experimental Study
Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis Sara Fereydounnia, Azadeh Shadmehr* Physiotherapy Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 January 2019 Received in revised form 13 May 2019 Accepted 20 May 2019
Introduction: The prevalence of lumbar hyper-lordosis is high in young women. Considering the previous studies into the effects of the whole body vibration (WBV) on the physiological parameters, the present study aimed to evaluate the immediate effects of WBV on the neurocognitive parameters in women with and without lumbar hyper-lordosis. Method: A total of 15 women with normal lumbar lordosis and 15 women with lumbar hyper-lordosis participated in the study. The effects of the WBV (30 Hz, 5 mm, and 5 min) on the visual and auditory reaction time and anticipatory skills were assessed using the Speed Anticipation Reaction Time (SART) Test. Results: The results indicated that the auditory complex choice reaction time decreased, and the anticipation skill with high speed increased after the WBV in women with normal lumbar lordosis (P ¼ 0.01, P ¼ 0.01, respectively). Additionally, the visual choice reaction time in women with lumbar hyperlordosis significantly decreased after WBV intervention. Although other variables in the two groups decreased after vibration, these changes were not statistically significant. Conclusion: The present study demonstrated that WBV had positive immediate effects on the reaction time in both groups, however, it had negative effects on anticipatory skill with high speed in women with normal lumbar lordosis; these negative effects appeared to be due to mental fatigue in the participants. This finding indicated WBV had the potential to enhance neuro-cognition. Therefore, further evaluations with different study settings and populations should be conducted. © 2019 Elsevier Ltd. All rights reserved.
1. Introduction Lumbar lordosis refers to the anterior shift in the lumbar arch. In the normal standing position, when viewed laterally, the arch will be at the midline of the body; however, in hyperlordosis, the midline of the lumbar arch will be posterior to the midline (Rahmawati and Sidarta, 2018). Harrison et al. and Troyanovich et al. stated that the normal curvature of the lumbar vertebra is approximately 39.7. The prevalence of lumbar hyperlordosis in students is approximately 49.75%. According to one study on the prevalence of lumbar malalignment in different age groups, 29.5% of the individuals had lumbar hyperlordosis, with a higher prevalence among adolescents (38.8%) and young women (48.7%)
* Corresponding author. School of Rehabilitation, Tehran University of Medical Sciences, PicheShemiran, Enghelab Street, Tehran, Iran. E-mail addresses: [email protected] (S. Fereydounnia), shadmehr@ tums.ac.ir (A. Shadmehr).
(Nazarian et al., 2010). Although hyperlordosis is not a serious anomaly, it has a high prevalence and could provide the basis for low back pain in the long term. It seems that the prevalence of low back pain in girls is higher than that in boys, as they are prone to hyperlordosis, and one of the most common reasons for low back pain is the change in the lumbar arch (Javid et al.). As a new finding, hyperlordosis is significantly associated with arthritis of the facet joints and the sagittal plane orientation of the lumbar spine. Therefore, hyperlordosis may appear with low back pain (Jentzsch et al., 2017). Neurocognitive activities such as measuring reaction time and processing speed, as used in many studies, represent brain function lu and Beyazova, (mainly the frontal lobe) (Milner, 1986; Turhanog 2003). Furthermore, situational awareness, arousal, and attentional resources may affect the function of the cerebral cortex. Consequently, it eliminates the complex coordination between the levels of information (cortical, subcortical, and somatosensory) needed for motor control (Swanik et al., 2007). A review study
https://doi.org/10.1016/j.jbmt.2019.05.030 1360-8592/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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suggested that weak coordination and slow psychomotor reaction time provide the basis for injury (Luoto et al., 1999). In addition, the results of some studies indicated that the reaction time of people with chronic low back pain was longer than that of people in the control group (Luoto, 1995; Luoto et al., 1999; Taimela et al., 1993). There is evidence revealing the importance of better reaction time in preventing musculoskeletal disorders. Whole-body vibration (WBV) can be described as an innovative neuromuscular method for training, in which a person is exposed to low-frequency vibrations. In contrast to the use of WBV combined with different exercises in sports and fitness, passive WBV is used when a static position (such as standing or sitting) is maintained with time. The benefits of WBV have been identified through various physiological measurements such as balance, mobility, postural control, oxygen uptake, heart rate, blood pressure, blood flow, and muscle strength (Fuermaier et al., 2014; Herrero et al., 2011; Rittweger et al., 2000, 2001; Yoosefinejad et al., 2015). When a person undergoes vibration training, they are placed on a plate with a frequency of 10e90 Hz and amplitude of 0.08e4 mm. These parameters may induce a stretch reflex response, which ultimately leads to the stimulation of Ia afferents and the irritability of the corticospinal pathways. In addition, the irritability of the inhibitory intracortical systems is affected by changes in afferent inputs (Mileva et al., 2009). In addition to possible stimulation of the muscle spindles, WBV can stimulate the Meissner corpuscles sensitive to the vibration in the skin. The mechanoreceptor signals are transmitted to the primary somatosensory cortex. The sensory association areas have connections to the prefrontal cortex. The indirect pathway includes the limbic system (e.g., amygdala and hippocampus, which are important areas for learning and memory), which can alter the effect of the sensory association area on the prefrontal cortex. Therefore, sensory stimulation may affect neuronal transmission in the sensory regions of the brain, such as the prefrontal cortex, hippocampus, and amygdala and also the other areas of the brain. Moreover, WBV significantly affects the forebrain through the activity of the cholinergic system. Furthermore, the immediate expression of the C-fos gene in the cortex areas involved in sensory-motor function, learning, and memory was increased in mice receiving WBV. C-fos enhances the neural transmission and switches in genes associated with the production of the proteins responsible for neural plasticity and long-term memory (Regterschot et al., 2014). Moreover, Ljungberg et al. reported an increase in awareness after vibration intervention (Ljungberg and Neely, 2007). Furthermore, there is increasing evidence that physical activity has a beneficial effect on cognition; executive functions, in particular, benefit from physical activity. Executive functions are a set of cognitive actions modifying and managing other cognitive actions to accomplish goals such as planning, working memory, mental flexibility, inhibition, attention, problem-solving, and multiple tasks, and they are associated with the prefrontal cortex. The passive WBV may be an alternative for those who cannot undertake physical activity for any reason (Regterschot et al., 2014). Hyperlordosis affects mechanical properties, such as causing muscle imbalance, and there are many studies that focus on this issue. In the present study, we examined women with lumbar hyperlordosis regardless of the cause and regarding the abovementioned cases; in this study, we focused only on the neurocognitive issue. Our rationale was based on previous studies (Luoto, 1995; Luoto et al., 1999) that showed a connection between slow psychomotor reaction time and low back pain, anda correlation between lumbar hyper lordosis and low back pain; in addition, there is evidence (Conway et al., 2007) that WBV could have positive effects on patients with low back pain. Hence, we hypothesized that WBV could have an effect on the neurocognitive skills
(reaction time and anticipatory skills) of women with and without lumbar hyperlordosis (its immediate effects on reaction time and memory have been shown in a different population), and aimed to evaluate this hypothesis. 2. Material and methods This study was approved by the Ethics Committee of the Tehran University of Medical Sciences and the Iranian Registry of Clinical Trials. The study was conducted in the Reaction Time Laboratory of the School of Rehabilitation, Tehran University of Medical Sciences. 2.1. Participants The study participants were recruited among students of the Tehran University of Medical Sciences through an announcement. A total of 15 women with normal lordosis (28.07 ± 2.68 years old, 162.20 ± 4.28 cm, 59 ± 6.97 kg) and 15 women with lumbar hyperlordosis (28.93 ± 3.45 years old, 161.07 ± 8.80 cm, 61.53 ± 9.39 kg) participated in the present study. 2.1.1. Inclusion criteria The participants’ age ranged between 18 and 32 years old, and they were right-handed. The participants did not have any hearing or visual problems and had normal color vision and discriminative ability. The participants were included in the normal lordosis group if they had normal lumbar lordosis (30e40 ), and they were included in the hyperlordosis group if they had increased lumbar lordosis (more than 40 ). 2.1.2. Exclusion criteria The participants were excluded if they had an injury to their neuromuscular and musculoskeletal systems, were taking any drugs or drinks affecting motor and cognitive function, or expressed dissatisfaction with continuing the experiment. 2.2. Study procedure Before conducting the test, the examiner explained the objectives and the procedure of the study to the participants. Then, the participants signed an informed consent form. At the beginning of the test session, demographic data were recorded, and their lumbar lordosis angle was measured. To measure lumbar lordosis, a flexible ruler was used, which is not as accurate as radiography, but safer and clinically acceptable. Two bony landmarks (spinous process of the T12 as the beginning of the arc and the S2 as the end of the arc) were marked with sticky removable red points when the participants stood on their feet and looked toward the opposite wall. In this position, two stabilizer arms, whose height and distance were adjustable from the ground, were placed on the xiphoid process of the sternum and the upper surface of the pubis symphysis, and they were kept fixed until the end of the measurement. The flexible ruler was then placed on the lumbar area to form a lumbar lordosis. Then, the ruler was set on the lumbar area between the two landmarks (S2 and T12). Without changing the shape of the ruler, its pattern was drawn on a white paper, and the T12 and S2 points were marked. To calculate the lumbar lordosis angle, the T12 and S2 points were measured by a straight line (L), and another line (H) was drawn perpendicular to the center of the arc. The lordosis angle was calculated by placing the values of L and H lines in the following formula (Youdas et al., 1995):
q ¼ 4 Arc tan
2H L
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
S. Fereydounnia, A. Shadmehr / Journal of Bodywork & Movement Therapies xxx (xxxx) xxx
After the participants were evaluated in terms of the inclusion criteria and the lumbar lordosis angle, individuals with normal lordosis (control group) were matched with those in the hyperlordosis group according to age and body mass index (BMI).
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2.3.3. Auditory choice reaction time test In this test, auditory stimulations were provided by four distinctive frequencies (500 Hz, 1000 Hz, 3000 Hz, and 7000 Hz). After hearing the sound, the participants had to push the related button on the joystick as quick as possible.
2.3. Speed Anticipation Reaction Time (SART) test system To show the SART test, a colored LCD (Samsung syncmaster B243HD, 24 inches, Korea) was connected to a laptop (Dell Vostro 1510). The SART software program consisted of six neurocognitive tests assessing the visual choice reaction time, visual complex choice reaction time, auditory choice reaction time, auditory complex choice reaction time, and anticipatory skill of the ball with high and low speed along with high inter-tester and intra-tester reliability (Nuri et al., 2013). All the participants became familiar with the testing procedure performed in the present study and did not have any experience with the SART setup; therefore, the training parameter was the same for all the participants. During the test, each of the participants was seated on a comfortable chair. The height of the chair was adjusted so that the participants’ feet were on the ground. The participants were seated at a distance of 2 m from the LCD monitor. The participants also held the joystick with two hands, and this position was the same for all the participants. To familiarize the participants with the system, they performed several trials of each test. The main tests began when the participants were acquainted with all the tests. 2.3.1. Visual choice reaction time test In this test, visual stimulations were provided by illuminating four lamps in red, yellow, green, and blue on the monitor. The examiner chose the button for each of the four colored lamps on the laptop, and the participants had to respond with the corresponding button on the joystick as quick as possible (Fig. 1). 2.3.2. Visual complex choice reaction time test The visual choice reaction time test was equipped with an incompatible mode enabled by activating it at the beginning of the program and by ticking the reverse key; therefore, it was possible to evaluate the complex choice reaction time, and the participants had to push the reverse button on the joystick after each stimulus.
2.3.4. Auditory choice reaction time test In this test, like the auditory choice reaction time test, stimuli were given, but the participants had to push the reverse button on the joystick for each stimulus. The output report of the reaction time tests indicated the average reaction time and the number of tests in which the error occurred. The reaction time tests were repeated in five sets of 10 repetitions measured with a measurement accuracy of 0.001 seconds.
2.3.5. Anticipatory skill with high and low speed On the anticipatory skill test page, a soccer ball horizontally moved from the right end of the screen to the left end toward the gate at a constant high or low speed (the examiner selected the speed randomly). On the left side, there was a black curtain, and the soccer ball disappeared when it reached the curtain. The participants had to guess the time the ball would arrive at the gate, according to the speed of the ball, and had to push the button on the joystick as quick as possible (Fig. 2). The output report of the anticipatory tests showed the average of total prediction time that did not result in abnormal response, Total User Tolerance (TUT: the difference between the actual time and the estimated time for the ball to reach the gate), and the number of times the participants had not responded for 10 seconds, leading to abnormal message. In the declared values, the negative value was the sign of late response and the positive value was the sign of earlier response than the actual time. The anticipatory skill test was repeated in three sets of 10 repetitions. The accuracy of this chronometer was 0.001 ms. Before and immediately after the WBV intervention, the visual and auditory reaction time tests and the anticipatory skills test were performed using the SART test system.
Fig. 1. Graphic User Interference of the visual and auditory reaction time test.
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Fig. 2. Graphic User Interference of anticipatory skill test.
2.4. Intervention
3. Results
A WBV system (Power Plate, USA) was used in the present study, which simultaneously transmitted energy based on the mass spring system. The participants stood bare feet on both feet without any movement on the WBV platform. The WBV was used with a frequency (30 Hz) and a high range (5 mm) including five sets of 1min vibration and 30 seconds of rest between each set.
The distribution of all outcome measures in both groups was normal, determined according to the values of the KolmogoroveSmirnov test. No significant difference was observed between the two groups regarding demographic data (P > 0.05) (Table 1). According to the results of the independent t-test, there was no significant difference between women in the lumbar hyperlordosis group and those in the control group concerning neurocognitive parameters before the intervention (P > 0.05). There was a significant difference in the auditory complex choice reaction time and anticipatory skill with high speed values (P ¼ 0.01, P ¼ 0.01, respectively) after vibration compared to the pretest values in the control group. The auditory complex choice reaction time decreased (163.99 ms) and anticipatory skill with high speed increased (þ245.38 ms). Other variables did not show significant difference when compared with the previbration values (Table 2). In the lumbar hyperlordosis group, no significant difference was observed between pre- and post-vibration values except for the visual complex choice reaction time (P > 0.03) (Table 3). According to the results obtained from the two-way repeatedmeasures ANOVA test, the vibration effect was significant for the auditory complex choice reaction time (P ¼ 0.01) and the
2.5. Statistical analysis SPSS (Statistical Package for the Social Sciences, version 19) was used to analyze all the outcome measures. To determine normal distribution of all variables, a sample of KolmogoroveSmirnov test was carried out (P > 0.05). Independent t-test was used to compare the demographic data between both groups. Independent t-test was used to compare the mean reaction time and anticipatory skills of the two groups before WBV intervention. Paired t-test was used to evaluate the effects of WBV on the mean reaction time and anticipatory skills in each group. The two-way repeated-measures ANOVA was used to evaluate the interaction effect of group (lumbar hyperlordosis and control) and vibration (before and after) on mean visual and auditory reaction times and anticipatory skills. Alpha level was set at 0.05 in all statistical tests.
Table 1 Comparison of the demographic data between women with lumbar hyperlordosis and control women by using independent t-test (n ¼ 15 in each group). Variables
Age (y) Weight (kg) Height (cm) BMI (kg/m2)
Mean ± SD Lumbar Hyperlordosis Group
Control group
28.93 ± 3.45 61.53 ± 9.39 161.07 ± 8.80 23.71 ± 3.10
28.07 ± 2.68 59.00 ± 6.97 162.20 ± 4.28 22.44 ± 2.62
Mean Difference
95% Confidence Interval
P Value
0.87 2.53 1.13 1.27
1.45e3.18 3.02e2.53 6.31e4.04 0.87e3.41
0.45 0.41 0.66 0.23
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
S. Fereydounnia, A. Shadmehr / Journal of Bodywork & Movement Therapies xxx (xxxx) xxx
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Table 2 Comparison of the mean reaction times and anticipatory skills before and after WBV intervention in women with normal lumbar lordosis (control group) by using paired t-test (n ¼ 15). Variables
Visual Choice Reaction Time (ms) Visual Complex Choice Reaction Time (ms) Auditory Choice Reaction Time (ms) Auditory Complex Choice Reaction Time (ms) Anticipatory Skill with High Speed (ms) Anticipatory Skill with Low Speed (ms)
Mean ± SD After vibration
Before vibration
442.05 ± 77.25 538.77 ± 77.85 887.11 ± 306.13 956.65 ± 258.72 929.51 ± 871.08 1257.60 ± 1177.61
444.47 ± 50.68 548.35 ± 92.18 932.83 ± 315.75 1120.64 ± 394.88 684.13 ± 674.96 1175.44 ± 894.13
Mean Difference
95% Confidence Interval
P Value
2.41 9.57 45.72 163.99 245.38 82.16
28.50e23.67 57.04e37.90 142.03e50.60 284.50e43.47 75.68e415.08 354.92e519.23
0.85 0.67 0.33 0.01* 0.01* 0.69
ms: millisecond.
Table 3 Comparison of the mean reaction times and anticipatory skills before and after WBV intervention in women with lumbar hyperlordosis by using paired t-test (n ¼ 15). Variables
Mean ± SD After vibration
Before vibration
Visual Choice Reaction Time (ms) Visual Complex Choice Reaction Time (ms) Auditory Choice Reaction Time (ms) Auditory Complex Choice Reaction Time (ms) Anticipatory Skill with High Speed (ms) Anticipatory Skill with Low Speed (ms)
400.67 ± 46.28 505.57 ± 76.65 837.89 ± 154.05 1025.27 ± 168.21 478.36 ± 387.24 1181.51 ± 1212.37
436.19 ± 68.33 529.47 ± 56.20 886.61 ± 146.71 1114.16 ± 298.29 437.36 ± 381.98 1035.00 ± 765.71
Mean Difference
95% Confidence Interval
P Value
35.52 23.89 48.72 88.89 41 146.51
67.20e3.84 58.74e10.95 117.55e20.11 223.22e45.43 157.99e239.99 342.70e635.72
0.03* 0.16 0.15 0.18 0.66 0.53
ms: millisecond.
anticipatory skill with high speed (P ¼ 0.03). Vibration effect, group effect, and their interaction effect for the other variables were not significant (P > 0.05).
4. Discussion The present study results demonstrated a significant reduction in the auditory complex choice reaction time and a significant increase in the anticipation skill with high speed after the WBV intervention in women with normal lumbar lordosis. Additionally, the visual choice reaction time in women with lumbar hyperlordosis significantly decreased after WBV intervention. Although other variables in the two groups reduced after vibration, these values were not statistically significant. Aerobic exercises as a kind of common physical activity have considerable benefits for people of all age groups. Furthermore, owing to its dominant influence on cardiovascular and musculoskeletal systems, it could also affect cognitive functions. Many studies have examined the effects of aerobic exercises on cognitive performance by reaction time. However, the results of these studies are contradictory (Collardeau et al., 2001; Davranche et al., 2006). Ashnagar et al. (2015) randomly divided healthy individuals into the intervention and control groups. The participants in the intervention group performed a sub-maximal bout of cycling, and the reaction times before and after the exercise were examined using the SART test system. In the control group, the visual and auditory reaction time tests were taken at a 30-min interval. In the intervention group, the percentage of changes in the mean auditory choice reaction time and auditory complex choice reaction time showed significant difference as compared to that of the control group. Although the visual choice reaction time and visual complex choice reaction time showed a reduction after intervention, they were not statistically significant (P > 0.05). Some authors suggested that physical activities could stimulate and activate the central nervous system through interstitial mechanisms. Therefore, they have a facilitating effect on the reaction time. Additionally, it is believed that aerobic exercises cause modulation of information processing through releasing the central
catecholamine. Furthermore, there are several neurophysiological mechanisms to explain the prolonged effects of exercise on the reaction time. In fact, angiogenesis and neurogenesis are structural changes in the brain caused by prolonged aerobic exercises (Audiffren et al., 2008; Churchill et al., 2002). The results of one study revealed that the choice reaction time decreases with increasing exercise intensity (Draper et al., 2010). A meta-analysis was used to investigate the effect of different acute intensities of exercise on the velocity and precision of cognition. The results showed that arousal increased during moderate exercise and led to faster processing (McMorris and Hale, 2012). These findings are discussed based on the inverted-U hypothesis proposed by Davey in 1973. Exercise was described as a stress factor, and as the intensity of exercise increases, the level of arousal increases. Recently, researchers have introduced the theory of reticular activation hyperfrontality. Based on this theory, moderate-intensity exercise triggers the reticular system, thereby increasing alertness and arousal and improving the performance of well-learned and habitual activities (Kashihara et al., 2009). Therefore, according to the effects of aerobic exercises and WBV on respiratory and cardiovascular factors, these theories may also be true for WBV, but thus far, only few investigations have been conducted on these theories. It has also been shown that changes in heart rate after WBV intervention not only depend on the sympathetic and parasympathetic balance but also directly correlate with the level of activity of the prefrontal cortex (Herrero et al., 2011). This is exactly the area in which cognitive information processing occurs. Previous studies showed that WBV could affect the timing and sequence of the muscle activity. The reaction time is a highly sensitive and objective variable representing the cognitive and motor performance. It has also been used to evaluate muscle function in lu and Beyazova, 2003). In many studies (Milner, 1986; Turhanog the studies conducted thus far, the effect of the WBV has been investigated on the total reaction time, premotor time, and motor time of a specific muscle by electromyographic recording. However, in this study, the calculated reaction time includes the amount of time spent on brain processing for a specific task, representing the cognitive function of the individual, not a specific muscle.
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Rittweger et al. (2003) indicated that the amplitude of stretch reflex after the squat with vibration was almost the same as that at baseline, or even slightly larger; however, it significantly decreased after the squat without vibration. This result was interesting, as decrease in power output and muscle strength in both exercises was almost the same. Given that the reduction of the amplitude of stretch reflex is a common finding after hard exercises, remaining the same or even increasing after the squat with vibration could be due to the central motor excitability, especially with regard to the considerable recruitment of phasic motor units. Thus, it can be concluded that 26-Hz WBV has been able to make changes in the neuromuscular recruitment pattern, which apparently increases the central neuromuscular excitability. Fuermaier et al. evaluated the effects of WBV on attention in adults with and without attention deficit hyperactivity disorder (ADHD) diagnosis. They indicated that WBV improved the cognitive function of healthy subjects, just like that in subjects with ADHD (Fuermaier et al., 2014). Amonette et al. showed that vibration (duration: 10 min, frequency: 30 Hz, and amplitude: 4 mm) with a 35-degree knee flexion had no negative effect on neurocognition, including five areas, namely, verbal memory, visual memory, speed of visual movement, reaction time, and impulse control (Amonette et al., 2015). Another study examined the effects of the 16-Hz sinusoidal wave of WBV on short-term memory task. The data suggested that vibration could interfere with the central cognitive mechanisms used during the short-term memory processing. However, compensatory cognitive processes may occur to reduce these effects (Sherwood and Griffin, 1990). Regterschot et al. showed that 2 min of WBV had immediate positive effects on attention in young people despite their high cognitive ability (Regterschot et al., 2014). Our results were consistent with those of this study, as in our study, the auditory complex choice reaction time was changed in the control group, which appeared to have good neurocognitive function. Mueller et al. showed that the beneficial effects of WBV (proprioceptive stimulation of forearm) were evaluated through neuropsychological performance (evaluated by computerized attentional task) and neurophysiological measurements (which were evaluated by the evoked potential) in patients with traumatic brain injury (TBI) and healthy subjects. In this study, proprioceptive stimulation improved the performance of patients with TBI and healthy subjects. In addition, patients with TBI had a longer eventrelated potential (ERP) delay (P300) than the healthy subjects. These delays improved after vibration in patients with TBI but did not change in the healthy subjects. Therefore, this study indicates that passive vibration could improve the pathological cognitive processes and therefore may be effective in the treatment of cognitive dysfunctions and neurocognitive rehabilitation (Müller et al., 2002). Our study results were consistent with those of the mentioned studies regarding the effect of WBV on improving reaction time in both groups of participants. As WBV is relatively inexpensive, easily useable, and available, it is suitable for clinical use. The findings suggest that WBV has the potential to enhance cognition, especially in people not able to practice. Furthermore, the anticipatory skill is a strategy to reduce the reaction time or even reduce the processing stages, which naturally applies when responding to an unpredictable stimulus. Individuals with higher anticipatory skills have the following abilities: efficient and effective use of the visual system (Savelsbergh et al., 2005), skillful motor behaviors (Aglioti et al., 2008), choice of an appro~ al-Bruland and priate response due to special experiences (Can Schmidt, 2009), and recognition of the best pattern of movement based on recall (Williams et al., 2006). Anticipatory skills are not a process in which the changes occur in a short time; therefore,
improving it involves forming new synapses, which is timeconsuming. As some of the variables have been at a high level before applying the vibration, we should not expect them to change much after applying the vibration. In our study, the anticipatory skills improved (but not statistically) in both groups, except for the anticipatory skill with high speed in the control group, which was increased. We speculated that this negative effect was, to some extent, due to mental fatigue of the participants, as it took 90 min (pre- and postvibration) to evaluate the neurocognitive parameters. Although some studies (Conway et al., 2007) demonstrated the adverse influence of high-frequency (above 60 Hz) vibration on goal-dependent activities such as visual perception and fine motor control, we used low-frequency vibration with a short duration. On the other hand, longitudinal observation is essential for monitoring the disease progression or assessing efficacy of the rehabilitative interventions; however, by repetitive testing, the phenomenon of “practice effect” may occur, which is a confounding variable and has the potential to complicate the result interpretation. By serial assessments, a participant's performance may improve for several reasons such as reduced stress, increased familiarity with the testing environment, and procedural learning, which can lead to false conclusions about the effectiveness of a treatment (Bartels et al., 2010). In addition to this, neurocognitive parameters are affected by various factors such as intelligence, education, mental fatigue, and emotional status. Hence, considering the above-mentioned studies and our results, it can be concluded that low-frequency WBV has immediate effects on neurological skills. This seems occur by enhancing the arousal and activating the central nervous system, but we cannot draw a firm conclusion about the actual effects of WBV and do not yet fully understand how much of the improvements are due to WBV or practice effects. 4.1. Limitations of the study The present study had some limitations. The sample size was too small to fully reflect the reaction time. Many factors such as mental fatigue, intelligence, stress, life events, emotional control, and personality can affect the reaction time and the neurocognitive function. Therefore, the selection of comparison groups is a challenge in such a caseecontrol study, although we attempted to reduce this bias by random selection of the participants. Another way to reduce the effects of these factors is to assess a large sample size. In this study, we focused only on women to prevent misinterpretation because sexual dimorphism is evident in several aspects of the lumbar vertebrae such as degree and pattern of dorsal wedging that forms the lumbar lordosis, the zygapophyseal surface area, and its orientation. Therefore, it also would be necessary to consider men in later studies. In addition, we defined the age range (18e32 years old) to omit the influence of aging on neurocognitive skills. An investigation of different age groups is recommended for future studies. The gold standard for measuring lumbar lordosis angle is by radiography of spine in the lateral view, but owing to ethical issues, we were not allowed to prescribe radiography specifically for healthy subjects, and therefore, we selected the flexible ruler as a viable alternative. Additionally, it was not possible to evaluate the reaction time during the WBV intervention by the SART test; if we could assess the reaction time during the intervention, maybe the changes would have been more significant. On the other hand, practice effects are prominent particularly in repetitive cognitive testing, and they might lead to an overestimation of the intervention effects. In future studies, we recommend improving the sensitivity of WBV effects on neurocognitive parameters by defining a control group with placebo WBV and evaluating its effects on pre- and post-results. Finally, it is necessary to
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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mention that women with hyperlordosis had a deviation from the average, but they were functionally healthy subjects with imperfect anatomy, which was not necessarily pathological. It would be better to assess subjects with pain and disability, which limit their function. 4.2. Future research directions Future studies should be conducted to obtain the desired duration, frequency, and amplitude to achieve the desired cognitive function. In addition, we reported the findings focused on the participants with lumbar hyperlordosis. Accordingly, future studies should examine the potential influences of WBV as a therapeutic aid or cognition enhancement tool for individuals with other musculoskeletal disorders and elderly participants or patients with traumatic injury who seem to have lower neurocognitive abilities. 4.3. Conclusion The present study revealed that passive WBV (frequency ¼ 30 Hz, amplitude ¼ 5 mm, duration ¼ 5 min) had immediate positive effects on the auditory complex choice reaction time of women with normal lumbar lordosis and on the visual choice reaction time of women with lumbar hyperlordosis. Although it had adverse effects on the anticipatory skill with high speed in women with normal lumbar lordosis, these adverse effects appeared to be due to mental fatigue in the participants. This finding indicated that WBV has the potential to enhance neurocognition. Thus, further assessment with different study settings and populations should be conducted. 4.4. Clinical relevance WBV had immediate positive effects on the auditory complex choice reaction time of women with normal lumbar lordosis. WBV had immediate positive effects on the visual choice reaction time of women with lumbar hyperlordosis From these results, it seems that clinicians could employ lowfrequency vibration with caution, for enhancing neurocognitive parameters in participants with lumbar hyperlordosis if their cognitive function is affected. Acknowledgments The research was supported by the Tehran University of Medical Sciences (TUMS) and Health Services (Grant no.: 95-02-32-32253). We would thank all the participants who participated in the present study and the personnel of the School of Rehabilitation. References Aglioti, S.M., Cesari, P., Romani, M., Urgesi, C., 2008. Action anticipation and motor resonance in elite basketball players. Nat. Neurosci. 11, 1109. Amonette, W.E., Boyle, M., Psarakis, M.B., Barker, J., Dupler, T.L., Ott, S.D., 2015. Neurocognitive responses to a single session of static squats with whole body vibration. J. Strength Cond. Res. 29, 96e100. Ashnagar, Z., Shadmehr, A., Jalaei, S., 2015. The effects of acute bout of cycling on auditory & visual reaction times. J. Bodyw. Mov. Ther. 19, 268e272. Audiffren, M., Tomporowski, P.D., Zagrodnik, J., 2008. Acute aerobic exercise and information processing: energizing motor processes during a choice reaction time task. Acta Psychol. 129, 410e419. Bartels, C., Wegrzyn, M., Wiedl, A., Ackermann, V., Ehrenreich, H., 2010. Practice effects in healthy adults: a longitudinal study on frequent repetitive cognitive testing. BMC Neurosci. 11, 118. ~ al-Bruland, R., Schmidt, M., 2009. Response bias in judging deceptive moveCan ments. Acta Psychol. 130, 235e240.
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Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Mentored Research: Experimental Study
Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis Sara Fereydounnia, Azadeh Shadmehr* Physiotherapy Department, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran
a r t i c l e i n f o
a b s t r a c t
Article history: Received 29 January 2019 Received in revised form 13 May 2019 Accepted 20 May 2019
Introduction: The prevalence of lumbar hyper-lordosis is high in young women. Considering the previous studies into the effects of the whole body vibration (WBV) on the physiological parameters, the present study aimed to evaluate the immediate effects of WBV on the neurocognitive parameters in women with and without lumbar hyper-lordosis. Method: A total of 15 women with normal lumbar lordosis and 15 women with lumbar hyper-lordosis participated in the study. The effects of the WBV (30 Hz, 5 mm, and 5 min) on the visual and auditory reaction time and anticipatory skills were assessed using the Speed Anticipation Reaction Time (SART) Test. Results: The results indicated that the auditory complex choice reaction time decreased, and the anticipation skill with high speed increased after the WBV in women with normal lumbar lordosis (P ¼ 0.01, P ¼ 0.01, respectively). Additionally, the visual choice reaction time in women with lumbar hyperlordosis significantly decreased after WBV intervention. Although other variables in the two groups decreased after vibration, these changes were not statistically significant. Conclusion: The present study demonstrated that WBV had positive immediate effects on the reaction time in both groups, however, it had negative effects on anticipatory skill with high speed in women with normal lumbar lordosis; these negative effects appeared to be due to mental fatigue in the participants. This finding indicated WBV had the potential to enhance neuro-cognition. Therefore, further evaluations with different study settings and populations should be conducted. © 2019 Elsevier Ltd. All rights reserved.
1. Introduction Lumbar lordosis refers to the anterior shift in the lumbar arch. In the normal standing position, when viewed laterally, the arch will be at the midline of the body; however, in hyperlordosis, the midline of the lumbar arch will be posterior to the midline (Rahmawati and Sidarta, 2018). Harrison et al. and Troyanovich et al. stated that the normal curvature of the lumbar vertebra is approximately 39.7. The prevalence of lumbar hyperlordosis in students is approximately 49.75%. According to one study on the prevalence of lumbar malalignment in different age groups, 29.5% of the individuals had lumbar hyperlordosis, with a higher prevalence among adolescents (38.8%) and young women (48.7%)
* Corresponding author. School of Rehabilitation, Tehran University of Medical Sciences, PicheShemiran, Enghelab Street, Tehran, Iran. E-mail addresses: [email protected] (S. Fereydounnia), shadmehr@ tums.ac.ir (A. Shadmehr).
(Nazarian et al., 2010). Although hyperlordosis is not a serious anomaly, it has a high prevalence and could provide the basis for low back pain in the long term. It seems that the prevalence of low back pain in girls is higher than that in boys, as they are prone to hyperlordosis, and one of the most common reasons for low back pain is the change in the lumbar arch (Javid et al.). As a new finding, hyperlordosis is significantly associated with arthritis of the facet joints and the sagittal plane orientation of the lumbar spine. Therefore, hyperlordosis may appear with low back pain (Jentzsch et al., 2017). Neurocognitive activities such as measuring reaction time and processing speed, as used in many studies, represent brain function lu and Beyazova, (mainly the frontal lobe) (Milner, 1986; Turhanog 2003). Furthermore, situational awareness, arousal, and attentional resources may affect the function of the cerebral cortex. Consequently, it eliminates the complex coordination between the levels of information (cortical, subcortical, and somatosensory) needed for motor control (Swanik et al., 2007). A review study
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Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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suggested that weak coordination and slow psychomotor reaction time provide the basis for injury (Luoto et al., 1999). In addition, the results of some studies indicated that the reaction time of people with chronic low back pain was longer than that of people in the control group (Luoto, 1995; Luoto et al., 1999; Taimela et al., 1993). There is evidence revealing the importance of better reaction time in preventing musculoskeletal disorders. Whole-body vibration (WBV) can be described as an innovative neuromuscular method for training, in which a person is exposed to low-frequency vibrations. In contrast to the use of WBV combined with different exercises in sports and fitness, passive WBV is used when a static position (such as standing or sitting) is maintained with time. The benefits of WBV have been identified through various physiological measurements such as balance, mobility, postural control, oxygen uptake, heart rate, blood pressure, blood flow, and muscle strength (Fuermaier et al., 2014; Herrero et al., 2011; Rittweger et al., 2000, 2001; Yoosefinejad et al., 2015). When a person undergoes vibration training, they are placed on a plate with a frequency of 10e90 Hz and amplitude of 0.08e4 mm. These parameters may induce a stretch reflex response, which ultimately leads to the stimulation of Ia afferents and the irritability of the corticospinal pathways. In addition, the irritability of the inhibitory intracortical systems is affected by changes in afferent inputs (Mileva et al., 2009). In addition to possible stimulation of the muscle spindles, WBV can stimulate the Meissner corpuscles sensitive to the vibration in the skin. The mechanoreceptor signals are transmitted to the primary somatosensory cortex. The sensory association areas have connections to the prefrontal cortex. The indirect pathway includes the limbic system (e.g., amygdala and hippocampus, which are important areas for learning and memory), which can alter the effect of the sensory association area on the prefrontal cortex. Therefore, sensory stimulation may affect neuronal transmission in the sensory regions of the brain, such as the prefrontal cortex, hippocampus, and amygdala and also the other areas of the brain. Moreover, WBV significantly affects the forebrain through the activity of the cholinergic system. Furthermore, the immediate expression of the C-fos gene in the cortex areas involved in sensory-motor function, learning, and memory was increased in mice receiving WBV. C-fos enhances the neural transmission and switches in genes associated with the production of the proteins responsible for neural plasticity and long-term memory (Regterschot et al., 2014). Moreover, Ljungberg et al. reported an increase in awareness after vibration intervention (Ljungberg and Neely, 2007). Furthermore, there is increasing evidence that physical activity has a beneficial effect on cognition; executive functions, in particular, benefit from physical activity. Executive functions are a set of cognitive actions modifying and managing other cognitive actions to accomplish goals such as planning, working memory, mental flexibility, inhibition, attention, problem-solving, and multiple tasks, and they are associated with the prefrontal cortex. The passive WBV may be an alternative for those who cannot undertake physical activity for any reason (Regterschot et al., 2014). Hyperlordosis affects mechanical properties, such as causing muscle imbalance, and there are many studies that focus on this issue. In the present study, we examined women with lumbar hyperlordosis regardless of the cause and regarding the abovementioned cases; in this study, we focused only on the neurocognitive issue. Our rationale was based on previous studies (Luoto, 1995; Luoto et al., 1999) that showed a connection between slow psychomotor reaction time and low back pain, anda correlation between lumbar hyper lordosis and low back pain; in addition, there is evidence (Conway et al., 2007) that WBV could have positive effects on patients with low back pain. Hence, we hypothesized that WBV could have an effect on the neurocognitive skills
(reaction time and anticipatory skills) of women with and without lumbar hyperlordosis (its immediate effects on reaction time and memory have been shown in a different population), and aimed to evaluate this hypothesis. 2. Material and methods This study was approved by the Ethics Committee of the Tehran University of Medical Sciences and the Iranian Registry of Clinical Trials. The study was conducted in the Reaction Time Laboratory of the School of Rehabilitation, Tehran University of Medical Sciences. 2.1. Participants The study participants were recruited among students of the Tehran University of Medical Sciences through an announcement. A total of 15 women with normal lordosis (28.07 ± 2.68 years old, 162.20 ± 4.28 cm, 59 ± 6.97 kg) and 15 women with lumbar hyperlordosis (28.93 ± 3.45 years old, 161.07 ± 8.80 cm, 61.53 ± 9.39 kg) participated in the present study. 2.1.1. Inclusion criteria The participants’ age ranged between 18 and 32 years old, and they were right-handed. The participants did not have any hearing or visual problems and had normal color vision and discriminative ability. The participants were included in the normal lordosis group if they had normal lumbar lordosis (30e40 ), and they were included in the hyperlordosis group if they had increased lumbar lordosis (more than 40 ). 2.1.2. Exclusion criteria The participants were excluded if they had an injury to their neuromuscular and musculoskeletal systems, were taking any drugs or drinks affecting motor and cognitive function, or expressed dissatisfaction with continuing the experiment. 2.2. Study procedure Before conducting the test, the examiner explained the objectives and the procedure of the study to the participants. Then, the participants signed an informed consent form. At the beginning of the test session, demographic data were recorded, and their lumbar lordosis angle was measured. To measure lumbar lordosis, a flexible ruler was used, which is not as accurate as radiography, but safer and clinically acceptable. Two bony landmarks (spinous process of the T12 as the beginning of the arc and the S2 as the end of the arc) were marked with sticky removable red points when the participants stood on their feet and looked toward the opposite wall. In this position, two stabilizer arms, whose height and distance were adjustable from the ground, were placed on the xiphoid process of the sternum and the upper surface of the pubis symphysis, and they were kept fixed until the end of the measurement. The flexible ruler was then placed on the lumbar area to form a lumbar lordosis. Then, the ruler was set on the lumbar area between the two landmarks (S2 and T12). Without changing the shape of the ruler, its pattern was drawn on a white paper, and the T12 and S2 points were marked. To calculate the lumbar lordosis angle, the T12 and S2 points were measured by a straight line (L), and another line (H) was drawn perpendicular to the center of the arc. The lordosis angle was calculated by placing the values of L and H lines in the following formula (Youdas et al., 1995):
q ¼ 4 Arc tan
2H L
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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After the participants were evaluated in terms of the inclusion criteria and the lumbar lordosis angle, individuals with normal lordosis (control group) were matched with those in the hyperlordosis group according to age and body mass index (BMI).
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2.3.3. Auditory choice reaction time test In this test, auditory stimulations were provided by four distinctive frequencies (500 Hz, 1000 Hz, 3000 Hz, and 7000 Hz). After hearing the sound, the participants had to push the related button on the joystick as quick as possible.
2.3. Speed Anticipation Reaction Time (SART) test system To show the SART test, a colored LCD (Samsung syncmaster B243HD, 24 inches, Korea) was connected to a laptop (Dell Vostro 1510). The SART software program consisted of six neurocognitive tests assessing the visual choice reaction time, visual complex choice reaction time, auditory choice reaction time, auditory complex choice reaction time, and anticipatory skill of the ball with high and low speed along with high inter-tester and intra-tester reliability (Nuri et al., 2013). All the participants became familiar with the testing procedure performed in the present study and did not have any experience with the SART setup; therefore, the training parameter was the same for all the participants. During the test, each of the participants was seated on a comfortable chair. The height of the chair was adjusted so that the participants’ feet were on the ground. The participants were seated at a distance of 2 m from the LCD monitor. The participants also held the joystick with two hands, and this position was the same for all the participants. To familiarize the participants with the system, they performed several trials of each test. The main tests began when the participants were acquainted with all the tests. 2.3.1. Visual choice reaction time test In this test, visual stimulations were provided by illuminating four lamps in red, yellow, green, and blue on the monitor. The examiner chose the button for each of the four colored lamps on the laptop, and the participants had to respond with the corresponding button on the joystick as quick as possible (Fig. 1). 2.3.2. Visual complex choice reaction time test The visual choice reaction time test was equipped with an incompatible mode enabled by activating it at the beginning of the program and by ticking the reverse key; therefore, it was possible to evaluate the complex choice reaction time, and the participants had to push the reverse button on the joystick after each stimulus.
2.3.4. Auditory choice reaction time test In this test, like the auditory choice reaction time test, stimuli were given, but the participants had to push the reverse button on the joystick for each stimulus. The output report of the reaction time tests indicated the average reaction time and the number of tests in which the error occurred. The reaction time tests were repeated in five sets of 10 repetitions measured with a measurement accuracy of 0.001 seconds.
2.3.5. Anticipatory skill with high and low speed On the anticipatory skill test page, a soccer ball horizontally moved from the right end of the screen to the left end toward the gate at a constant high or low speed (the examiner selected the speed randomly). On the left side, there was a black curtain, and the soccer ball disappeared when it reached the curtain. The participants had to guess the time the ball would arrive at the gate, according to the speed of the ball, and had to push the button on the joystick as quick as possible (Fig. 2). The output report of the anticipatory tests showed the average of total prediction time that did not result in abnormal response, Total User Tolerance (TUT: the difference between the actual time and the estimated time for the ball to reach the gate), and the number of times the participants had not responded for 10 seconds, leading to abnormal message. In the declared values, the negative value was the sign of late response and the positive value was the sign of earlier response than the actual time. The anticipatory skill test was repeated in three sets of 10 repetitions. The accuracy of this chronometer was 0.001 ms. Before and immediately after the WBV intervention, the visual and auditory reaction time tests and the anticipatory skills test were performed using the SART test system.
Fig. 1. Graphic User Interference of the visual and auditory reaction time test.
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Fig. 2. Graphic User Interference of anticipatory skill test.
2.4. Intervention
3. Results
A WBV system (Power Plate, USA) was used in the present study, which simultaneously transmitted energy based on the mass spring system. The participants stood bare feet on both feet without any movement on the WBV platform. The WBV was used with a frequency (30 Hz) and a high range (5 mm) including five sets of 1min vibration and 30 seconds of rest between each set.
The distribution of all outcome measures in both groups was normal, determined according to the values of the KolmogoroveSmirnov test. No significant difference was observed between the two groups regarding demographic data (P > 0.05) (Table 1). According to the results of the independent t-test, there was no significant difference between women in the lumbar hyperlordosis group and those in the control group concerning neurocognitive parameters before the intervention (P > 0.05). There was a significant difference in the auditory complex choice reaction time and anticipatory skill with high speed values (P ¼ 0.01, P ¼ 0.01, respectively) after vibration compared to the pretest values in the control group. The auditory complex choice reaction time decreased (163.99 ms) and anticipatory skill with high speed increased (þ245.38 ms). Other variables did not show significant difference when compared with the previbration values (Table 2). In the lumbar hyperlordosis group, no significant difference was observed between pre- and post-vibration values except for the visual complex choice reaction time (P > 0.03) (Table 3). According to the results obtained from the two-way repeatedmeasures ANOVA test, the vibration effect was significant for the auditory complex choice reaction time (P ¼ 0.01) and the
2.5. Statistical analysis SPSS (Statistical Package for the Social Sciences, version 19) was used to analyze all the outcome measures. To determine normal distribution of all variables, a sample of KolmogoroveSmirnov test was carried out (P > 0.05). Independent t-test was used to compare the demographic data between both groups. Independent t-test was used to compare the mean reaction time and anticipatory skills of the two groups before WBV intervention. Paired t-test was used to evaluate the effects of WBV on the mean reaction time and anticipatory skills in each group. The two-way repeated-measures ANOVA was used to evaluate the interaction effect of group (lumbar hyperlordosis and control) and vibration (before and after) on mean visual and auditory reaction times and anticipatory skills. Alpha level was set at 0.05 in all statistical tests.
Table 1 Comparison of the demographic data between women with lumbar hyperlordosis and control women by using independent t-test (n ¼ 15 in each group). Variables
Age (y) Weight (kg) Height (cm) BMI (kg/m2)
Mean ± SD Lumbar Hyperlordosis Group
Control group
28.93 ± 3.45 61.53 ± 9.39 161.07 ± 8.80 23.71 ± 3.10
28.07 ± 2.68 59.00 ± 6.97 162.20 ± 4.28 22.44 ± 2.62
Mean Difference
95% Confidence Interval
P Value
0.87 2.53 1.13 1.27
1.45e3.18 3.02e2.53 6.31e4.04 0.87e3.41
0.45 0.41 0.66 0.23
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Table 2 Comparison of the mean reaction times and anticipatory skills before and after WBV intervention in women with normal lumbar lordosis (control group) by using paired t-test (n ¼ 15). Variables
Visual Choice Reaction Time (ms) Visual Complex Choice Reaction Time (ms) Auditory Choice Reaction Time (ms) Auditory Complex Choice Reaction Time (ms) Anticipatory Skill with High Speed (ms) Anticipatory Skill with Low Speed (ms)
Mean ± SD After vibration
Before vibration
442.05 ± 77.25 538.77 ± 77.85 887.11 ± 306.13 956.65 ± 258.72 929.51 ± 871.08 1257.60 ± 1177.61
444.47 ± 50.68 548.35 ± 92.18 932.83 ± 315.75 1120.64 ± 394.88 684.13 ± 674.96 1175.44 ± 894.13
Mean Difference
95% Confidence Interval
P Value
2.41 9.57 45.72 163.99 245.38 82.16
28.50e23.67 57.04e37.90 142.03e50.60 284.50e43.47 75.68e415.08 354.92e519.23
0.85 0.67 0.33 0.01* 0.01* 0.69
ms: millisecond.
Table 3 Comparison of the mean reaction times and anticipatory skills before and after WBV intervention in women with lumbar hyperlordosis by using paired t-test (n ¼ 15). Variables
Mean ± SD After vibration
Before vibration
Visual Choice Reaction Time (ms) Visual Complex Choice Reaction Time (ms) Auditory Choice Reaction Time (ms) Auditory Complex Choice Reaction Time (ms) Anticipatory Skill with High Speed (ms) Anticipatory Skill with Low Speed (ms)
400.67 ± 46.28 505.57 ± 76.65 837.89 ± 154.05 1025.27 ± 168.21 478.36 ± 387.24 1181.51 ± 1212.37
436.19 ± 68.33 529.47 ± 56.20 886.61 ± 146.71 1114.16 ± 298.29 437.36 ± 381.98 1035.00 ± 765.71
Mean Difference
95% Confidence Interval
P Value
35.52 23.89 48.72 88.89 41 146.51
67.20e3.84 58.74e10.95 117.55e20.11 223.22e45.43 157.99e239.99 342.70e635.72
0.03* 0.16 0.15 0.18 0.66 0.53
ms: millisecond.
anticipatory skill with high speed (P ¼ 0.03). Vibration effect, group effect, and their interaction effect for the other variables were not significant (P > 0.05).
4. Discussion The present study results demonstrated a significant reduction in the auditory complex choice reaction time and a significant increase in the anticipation skill with high speed after the WBV intervention in women with normal lumbar lordosis. Additionally, the visual choice reaction time in women with lumbar hyperlordosis significantly decreased after WBV intervention. Although other variables in the two groups reduced after vibration, these values were not statistically significant. Aerobic exercises as a kind of common physical activity have considerable benefits for people of all age groups. Furthermore, owing to its dominant influence on cardiovascular and musculoskeletal systems, it could also affect cognitive functions. Many studies have examined the effects of aerobic exercises on cognitive performance by reaction time. However, the results of these studies are contradictory (Collardeau et al., 2001; Davranche et al., 2006). Ashnagar et al. (2015) randomly divided healthy individuals into the intervention and control groups. The participants in the intervention group performed a sub-maximal bout of cycling, and the reaction times before and after the exercise were examined using the SART test system. In the control group, the visual and auditory reaction time tests were taken at a 30-min interval. In the intervention group, the percentage of changes in the mean auditory choice reaction time and auditory complex choice reaction time showed significant difference as compared to that of the control group. Although the visual choice reaction time and visual complex choice reaction time showed a reduction after intervention, they were not statistically significant (P > 0.05). Some authors suggested that physical activities could stimulate and activate the central nervous system through interstitial mechanisms. Therefore, they have a facilitating effect on the reaction time. Additionally, it is believed that aerobic exercises cause modulation of information processing through releasing the central
catecholamine. Furthermore, there are several neurophysiological mechanisms to explain the prolonged effects of exercise on the reaction time. In fact, angiogenesis and neurogenesis are structural changes in the brain caused by prolonged aerobic exercises (Audiffren et al., 2008; Churchill et al., 2002). The results of one study revealed that the choice reaction time decreases with increasing exercise intensity (Draper et al., 2010). A meta-analysis was used to investigate the effect of different acute intensities of exercise on the velocity and precision of cognition. The results showed that arousal increased during moderate exercise and led to faster processing (McMorris and Hale, 2012). These findings are discussed based on the inverted-U hypothesis proposed by Davey in 1973. Exercise was described as a stress factor, and as the intensity of exercise increases, the level of arousal increases. Recently, researchers have introduced the theory of reticular activation hyperfrontality. Based on this theory, moderate-intensity exercise triggers the reticular system, thereby increasing alertness and arousal and improving the performance of well-learned and habitual activities (Kashihara et al., 2009). Therefore, according to the effects of aerobic exercises and WBV on respiratory and cardiovascular factors, these theories may also be true for WBV, but thus far, only few investigations have been conducted on these theories. It has also been shown that changes in heart rate after WBV intervention not only depend on the sympathetic and parasympathetic balance but also directly correlate with the level of activity of the prefrontal cortex (Herrero et al., 2011). This is exactly the area in which cognitive information processing occurs. Previous studies showed that WBV could affect the timing and sequence of the muscle activity. The reaction time is a highly sensitive and objective variable representing the cognitive and motor performance. It has also been used to evaluate muscle function in lu and Beyazova, 2003). In many studies (Milner, 1986; Turhanog the studies conducted thus far, the effect of the WBV has been investigated on the total reaction time, premotor time, and motor time of a specific muscle by electromyographic recording. However, in this study, the calculated reaction time includes the amount of time spent on brain processing for a specific task, representing the cognitive function of the individual, not a specific muscle.
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
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Rittweger et al. (2003) indicated that the amplitude of stretch reflex after the squat with vibration was almost the same as that at baseline, or even slightly larger; however, it significantly decreased after the squat without vibration. This result was interesting, as decrease in power output and muscle strength in both exercises was almost the same. Given that the reduction of the amplitude of stretch reflex is a common finding after hard exercises, remaining the same or even increasing after the squat with vibration could be due to the central motor excitability, especially with regard to the considerable recruitment of phasic motor units. Thus, it can be concluded that 26-Hz WBV has been able to make changes in the neuromuscular recruitment pattern, which apparently increases the central neuromuscular excitability. Fuermaier et al. evaluated the effects of WBV on attention in adults with and without attention deficit hyperactivity disorder (ADHD) diagnosis. They indicated that WBV improved the cognitive function of healthy subjects, just like that in subjects with ADHD (Fuermaier et al., 2014). Amonette et al. showed that vibration (duration: 10 min, frequency: 30 Hz, and amplitude: 4 mm) with a 35-degree knee flexion had no negative effect on neurocognition, including five areas, namely, verbal memory, visual memory, speed of visual movement, reaction time, and impulse control (Amonette et al., 2015). Another study examined the effects of the 16-Hz sinusoidal wave of WBV on short-term memory task. The data suggested that vibration could interfere with the central cognitive mechanisms used during the short-term memory processing. However, compensatory cognitive processes may occur to reduce these effects (Sherwood and Griffin, 1990). Regterschot et al. showed that 2 min of WBV had immediate positive effects on attention in young people despite their high cognitive ability (Regterschot et al., 2014). Our results were consistent with those of this study, as in our study, the auditory complex choice reaction time was changed in the control group, which appeared to have good neurocognitive function. Mueller et al. showed that the beneficial effects of WBV (proprioceptive stimulation of forearm) were evaluated through neuropsychological performance (evaluated by computerized attentional task) and neurophysiological measurements (which were evaluated by the evoked potential) in patients with traumatic brain injury (TBI) and healthy subjects. In this study, proprioceptive stimulation improved the performance of patients with TBI and healthy subjects. In addition, patients with TBI had a longer eventrelated potential (ERP) delay (P300) than the healthy subjects. These delays improved after vibration in patients with TBI but did not change in the healthy subjects. Therefore, this study indicates that passive vibration could improve the pathological cognitive processes and therefore may be effective in the treatment of cognitive dysfunctions and neurocognitive rehabilitation (Müller et al., 2002). Our study results were consistent with those of the mentioned studies regarding the effect of WBV on improving reaction time in both groups of participants. As WBV is relatively inexpensive, easily useable, and available, it is suitable for clinical use. The findings suggest that WBV has the potential to enhance cognition, especially in people not able to practice. Furthermore, the anticipatory skill is a strategy to reduce the reaction time or even reduce the processing stages, which naturally applies when responding to an unpredictable stimulus. Individuals with higher anticipatory skills have the following abilities: efficient and effective use of the visual system (Savelsbergh et al., 2005), skillful motor behaviors (Aglioti et al., 2008), choice of an appro~ al-Bruland and priate response due to special experiences (Can Schmidt, 2009), and recognition of the best pattern of movement based on recall (Williams et al., 2006). Anticipatory skills are not a process in which the changes occur in a short time; therefore,
improving it involves forming new synapses, which is timeconsuming. As some of the variables have been at a high level before applying the vibration, we should not expect them to change much after applying the vibration. In our study, the anticipatory skills improved (but not statistically) in both groups, except for the anticipatory skill with high speed in the control group, which was increased. We speculated that this negative effect was, to some extent, due to mental fatigue of the participants, as it took 90 min (pre- and postvibration) to evaluate the neurocognitive parameters. Although some studies (Conway et al., 2007) demonstrated the adverse influence of high-frequency (above 60 Hz) vibration on goal-dependent activities such as visual perception and fine motor control, we used low-frequency vibration with a short duration. On the other hand, longitudinal observation is essential for monitoring the disease progression or assessing efficacy of the rehabilitative interventions; however, by repetitive testing, the phenomenon of “practice effect” may occur, which is a confounding variable and has the potential to complicate the result interpretation. By serial assessments, a participant's performance may improve for several reasons such as reduced stress, increased familiarity with the testing environment, and procedural learning, which can lead to false conclusions about the effectiveness of a treatment (Bartels et al., 2010). In addition to this, neurocognitive parameters are affected by various factors such as intelligence, education, mental fatigue, and emotional status. Hence, considering the above-mentioned studies and our results, it can be concluded that low-frequency WBV has immediate effects on neurological skills. This seems occur by enhancing the arousal and activating the central nervous system, but we cannot draw a firm conclusion about the actual effects of WBV and do not yet fully understand how much of the improvements are due to WBV or practice effects. 4.1. Limitations of the study The present study had some limitations. The sample size was too small to fully reflect the reaction time. Many factors such as mental fatigue, intelligence, stress, life events, emotional control, and personality can affect the reaction time and the neurocognitive function. Therefore, the selection of comparison groups is a challenge in such a caseecontrol study, although we attempted to reduce this bias by random selection of the participants. Another way to reduce the effects of these factors is to assess a large sample size. In this study, we focused only on women to prevent misinterpretation because sexual dimorphism is evident in several aspects of the lumbar vertebrae such as degree and pattern of dorsal wedging that forms the lumbar lordosis, the zygapophyseal surface area, and its orientation. Therefore, it also would be necessary to consider men in later studies. In addition, we defined the age range (18e32 years old) to omit the influence of aging on neurocognitive skills. An investigation of different age groups is recommended for future studies. The gold standard for measuring lumbar lordosis angle is by radiography of spine in the lateral view, but owing to ethical issues, we were not allowed to prescribe radiography specifically for healthy subjects, and therefore, we selected the flexible ruler as a viable alternative. Additionally, it was not possible to evaluate the reaction time during the WBV intervention by the SART test; if we could assess the reaction time during the intervention, maybe the changes would have been more significant. On the other hand, practice effects are prominent particularly in repetitive cognitive testing, and they might lead to an overestimation of the intervention effects. In future studies, we recommend improving the sensitivity of WBV effects on neurocognitive parameters by defining a control group with placebo WBV and evaluating its effects on pre- and post-results. Finally, it is necessary to
Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030
S. Fereydounnia, A. Shadmehr / Journal of Bodywork & Movement Therapies xxx (xxxx) xxx
mention that women with hyperlordosis had a deviation from the average, but they were functionally healthy subjects with imperfect anatomy, which was not necessarily pathological. It would be better to assess subjects with pain and disability, which limit their function. 4.2. Future research directions Future studies should be conducted to obtain the desired duration, frequency, and amplitude to achieve the desired cognitive function. In addition, we reported the findings focused on the participants with lumbar hyperlordosis. Accordingly, future studies should examine the potential influences of WBV as a therapeutic aid or cognition enhancement tool for individuals with other musculoskeletal disorders and elderly participants or patients with traumatic injury who seem to have lower neurocognitive abilities. 4.3. Conclusion The present study revealed that passive WBV (frequency ¼ 30 Hz, amplitude ¼ 5 mm, duration ¼ 5 min) had immediate positive effects on the auditory complex choice reaction time of women with normal lumbar lordosis and on the visual choice reaction time of women with lumbar hyperlordosis. Although it had adverse effects on the anticipatory skill with high speed in women with normal lumbar lordosis, these adverse effects appeared to be due to mental fatigue in the participants. This finding indicated that WBV has the potential to enhance neurocognition. Thus, further assessment with different study settings and populations should be conducted. 4.4. Clinical relevance WBV had immediate positive effects on the auditory complex choice reaction time of women with normal lumbar lordosis. WBV had immediate positive effects on the visual choice reaction time of women with lumbar hyperlordosis From these results, it seems that clinicians could employ lowfrequency vibration with caution, for enhancing neurocognitive parameters in participants with lumbar hyperlordosis if their cognitive function is affected. Acknowledgments The research was supported by the Tehran University of Medical Sciences (TUMS) and Health Services (Grant no.: 95-02-32-32253). We would thank all the participants who participated in the present study and the personnel of the School of Rehabilitation. References Aglioti, S.M., Cesari, P., Romani, M., Urgesi, C., 2008. Action anticipation and motor resonance in elite basketball players. Nat. Neurosci. 11, 1109. Amonette, W.E., Boyle, M., Psarakis, M.B., Barker, J., Dupler, T.L., Ott, S.D., 2015. Neurocognitive responses to a single session of static squats with whole body vibration. J. Strength Cond. Res. 29, 96e100. Ashnagar, Z., Shadmehr, A., Jalaei, S., 2015. The effects of acute bout of cycling on auditory & visual reaction times. J. Bodyw. Mov. Ther. 19, 268e272. Audiffren, M., Tomporowski, P.D., Zagrodnik, J., 2008. Acute aerobic exercise and information processing: energizing motor processes during a choice reaction time task. Acta Psychol. 129, 410e419. Bartels, C., Wegrzyn, M., Wiedl, A., Ackermann, V., Ehrenreich, H., 2010. Practice effects in healthy adults: a longitudinal study on frequent repetitive cognitive testing. BMC Neurosci. 11, 118. ~ al-Bruland, R., Schmidt, M., 2009. Response bias in judging deceptive moveCan ments. Acta Psychol. 130, 235e240.
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Please cite this article as: Fereydounnia, S., Shadmehr, A., Efficacy of whole body vibration on neurocognitive parameters in women with and without lumbar hyper-lordosis, Journal of Bodywork & Movement Therapies, https://doi.org/10.1016/j.jbmt.2019.05.030