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Tdcs and Sporting Performance: a Systematic Review and Meta

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Tdcs and Sporting Performance: a Systematic Review and Meta **This manuscript has not been peer reviewed 13/01/21** tDCS and sporting performance: A systematic review and meta-analysis of transcranial direct current stimulation effects on physical endurance, muscular strength, and visuomotor skills Trish Chinzara1,2, Gavin Buckingham1, David Harris1 1. Department of Sport and Health Science, University of Exeter, UK 2. Goldsmiths University of London, London, UK Correspondence concerning this article should be addressed to Dr David Harris, School of Sport and Health Sciences, University of Exeter, St Luke’s Campus, Exeter, EX1 2LU. Contact: [email protected]. ORCiD: https://orcid.org/0000-0003-3880-3856 Authors' CRediT contributions– TC: Conceptualization; Methodology; Data curation; Formal Analysis; Visualization; Writing – original draft. GB: Conceptualization; Methodology; Supervision; Writing – review & editing. DH: Conceptualization; Methodology; Formal Analysis; Visualization; Writing – review & editing. Declarations: The authors declare no conflicts of interest relevant to the present work. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 1 **This manuscript has not been peer reviewed 13/01/21** 1 2 Abstract 3 Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique 4 that has been linked with a range of physiological and cognitive enhancements relevant to 5 sporting performance. As a number of positive and null findings have been reported in the 6 literature, the present meta-analysis sought to synthesise results across endurance, strength 7 and visuomotor skill domains to investigate if tDCS improves any aspect of sporting 8 performance. Online database searches in August 2020 identified 43 full-text studies which 9 examined the acute effects of tDCS compared to sham/control conditions on physical 10 endurance, muscular strength and visuomotor skills in healthy adults. The quantitative 11 analysis indicated a small overall effect favouring tDCS stimulation over sham/control 12 (SMD=0.25, CI95%[0.14;0.36]). Effects on strength (SMD=0.31, CI95%[0.10;0.51]) and 13 visuomotor (SMD=0.29, CI95%[0.00;0.57]) tasks were larger than endurance performance 14 (SMD=0.18, CI95%[0.00;0.37]). Meta-regressions indicated effect sizes were not related to 15 stimulation parameters, but genetics, gender, and experience may modulate tDCS effects. The 16 results suggest tDCS has the potential to be used as an ergogenic aid in conjunction with a 17 specified training regime. 18 19 Keywords; ergogenic; neurodoping; neuroenhancement; sport; performance enhancement 2 **This manuscript has not been peer reviewed 13/01/21** 20 1. Introduction 21 Successful sporting performance is dependent on an athlete’s ability to consistently perform 22 at their peak. In the increasingly competitive sporting environment, there is heightened 23 pressure to mitigate factors that limit physical and cognitive performance for accelerated 24 results (Davis, 2013), which has prompted athletes to seek an advantage through ergogenic 25 aids and neuroenhancement (Banissy and Muggleton, 2013). Transcranial direct current 26 stimulation (tDCS) is a form of brain stimulation that has been linked with a range of 27 performance improvements in cognitive function (Banissy and Muggleton, 2013), exercise 28 endurance (Cogiamanian et al, 2007) and muscular strength (Hazime et al, 2017). tDCS has a 29 number of practical advantages over other methods of brain stimulation, such as transcranial 30 magnetic stimulation (TMS), due to the cost, safety, and portability of stimulation devices 31 (Davis, 2013; Bikson et al, 2016). The attraction for athletes is clear and tDCS has moved 32 outside of controlled laboratories to the wider community, with simulation kits being 33 endorsed by athletes as a quick alternative to improve performance (Mansfield, 2016; 34 Edwards, 2017). Yet, the accessibility of tDCS, rather than robust research findings, may 35 have driven adoption of the technique. 36 Transcranial stimulation paradigms have grown in popularity due to their potential to provide 37 a non-invasive method of modulating behaviour by increasing cortical excitability (Stagg and 38 Nitsche, 2011). tDCS has been explored in a variety of clinical conditions (Bennabi and 39 Haffen, 2018; Inoue and Taneda, 2019; Lima and Fregni, 2008), but as well as treating 40 clinical conditions and impairments, tDCS has also been touted as a method of performance 41 enhancement or ‘neurodoping’ (Davis, 2013). If reliable, emerging tDCS effects could signal 42 considerable benefits in sport and related fields (e.g., the military or aviation) through 43 improvements in physiology, cognition, and motor learning. For instance, single session 44 tDCS may alleviate cognitive fatigue which impairs endurance performance (Reardon, 2016), 45 improve cognitive performance through exciting relevant higher brain areas through cross- 46 activation and modulating neuroplasticity (Stagg and Nitsche, 2011), and improve motor 47 performance or accelerate motor learning when used in conjunction with a pre-established 48 training regime (von Rein et al., 2015). 49 tDCS induces a weak but constant electrical current from a cathode (negative electrode) to an 50 anode (positive electrode) which modulates the activity of cortical neurons near the electrode, 51 and diffuse locations nearby (Stagg and Nitsche, 2011). tDCS stimulation is proposed to 52 facilitate neural activity through reducing the negative polarisation across the neural 3 **This manuscript has not been peer reviewed 13/01/21** 53 membrane at the anode or inhibit activity through hyperpolarisation at the cathode. The 54 polarity-dependent effects of tDCS may, however, be over-simplistic as a result of a non- 55 linear dose-response (i.e. possible anodal inhibition or cathodal excitation) (Esmaeilpour et 56 al., 2018; Jamil et al., 2016). Most tDCS devices use rubber electrodes, between 25-35cm2 in 57 size, applied to the scalp over a targeted brain region determined by the intended effect. 58 These electrodes provide current at a range of 1-2mA, typically activated for 10-20min. Side 59 effects are minimal with a mild tingling sensation being the most commonly reported 60 (70.6%) and insomnia (0.98%) being the worst (Poreisz et al, 2007). 61 The motor cortex (M1) is typically a target for stimulation due to its capability in sustaining 62 neural drive within motor neurons, thereby, improving performance by compensating for 63 central fatigue (Papale and Hooks, 2018). Studies have shown stimulation at this region 64 influences motor learning retention and corticospinal excitability in participants for up to an 65 hour after delivery (Nitsche and Paulus, 2007). Derosière et al (2014) showed increased 66 ipsilateral M1 activation during a unilateral handgrip task when the force was above 30% 67 maximum voluntary contraction (MVC), indicating a cross-activation effect. The cross- 68 activation/facilitation hypothesis is supported by evidence from Hendy et al (2014) who 69 report application of anodal tDCS to ipsilateral M1 resulted in an increase in maximal 70 strength and cross-activation. The results support a hypothetical model proposed by Lang et 71 al (2004), that tDCS can increase the synaptic effectiveness of corticospinal cells though 72 cross-activation making them last longer than the duration of polarisation. Cross-activation is 73 a phenomenon still being explored, however priming M1 using tDCS appears to encourage 74 the transfer of strength which partially explains its popularity as a target for sport 75 performance studies (Frazer et al, 2017). 76 Application of tDCS is not limited to the motor cortex, an alternative target for stimulation is 77 the dorsolateral prefrontal cortex (DLPFC). The prefrontal cortex is theorised to play a role in 78 fatigue-related feedback, and decreased prefrontal cortical oxygenation results in 79 performance failure in TTE cycling task (Thomas and Stephane, 2007). Therefore, 80 stimulating the area could increase neuronal activity to reinforce muscle feedback by 81 strengthening cognitive ability to delay exercise termination (Grandperrin et al., 2020). This 82 effect has been explored by Latteri et al (2018) who found activating the DLPFC increased 83 exercise tolerance. The benefits of PFC stimulation may also be derived from enhanced 84 working memory activity and its role in cognitive control (Boudewyn, Scangos, Ranganath 85 and Carter, 2020). 4 **This manuscript has not been peer reviewed 13/01/21** 86 While direct brain stimulation has been linked with a range of physiological and cognitive 87 benefits, inconsistent results and differential effects as a result of widely varying stimulation 88 protocols poses a challenge for interpreting overall efficacy (Dedoncker, Brunoni, Baeken 89 and Vanderhasselt, 2016). The duration of stimulation has been reported as a key determinant 90 of the prolongation of tDCS effects on performance outcomes. Nitsche and Paulus (2000) 91 report a significant elevation of motor-cortical excitability up to 40% after 10 minutes 92 compared to a stimulus duration of 5min (0.6mA). Similarly, Williams et al (2013) found a 93 group receiving stimulation throughout a submaximal isolated isometric time to task failure 94 (TTF) test had significantly improved endurance, whereas, the group receiving stimulation 95 for 50% of the TTF test did not show this improvement. 96 Similarly, the exact positioning of the surface electrodes
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