Potential Synergistic Effects of Single-Session tDCS and Guided Mindfulness on Balance and Pain in Athletes with Patellofemoral Pain: A Pilot Crossover Study

Potential Synergistic Effects of Single-Session tDCS and Guided Mindfulness on Balance and Pain in Athletes with Patellofemoral Pain: A Pilot Crossover Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Potential Synergistic Effects of Single-Session tDCS and Guided Mindfulness on Balance and Pain in Athletes with Patellofemoral Pain: A Pilot Crossover Study Masoud Esmaeilnejad, Fatemeh Zahra Maleki Gohar, Meysam Yavari Kateb, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7801576/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The objective of this study was to investigate the synergistic effect of a single-session combined transcranial direct current stimulation (tDCS) and mindfulness intervention on static and dynamic single-leg balance and pain intensity in athletes with patellofemoral pain syndrome (PFPS). Ten athletes with PFPS participated in a pilot randomized crossover study. Each participant received active tDCS-Mindfulness and Sham-Mindfulness in randomized order, with a one-week interval between sessions; participants were not informed of the condition. Both groups received a 20-minute intervention (anode over C3, 2 mA) while listening to brief guided mindfulness; in the Sham-Mindfulness group the current was discontinued after 30 seconds. Participants completed single-leg balance tests on the Biodex Balance System (BBS) and rated pain intensity on a 10-cm Visual Analogue Scale (VAS). Following initial assessments, covariance analysis was performed. Between-group comparisons showed that a single-session combined tDCS-Mindfulness produced improvements in overall static and dynamic single-leg balance and reduced pain intensity (p 0.05). This study suggests that a brief, tDCS-mindfulness intervention can confer modest, immediate improvements in balance and reduce pain in athletes with PFPS. This approach could represent a promising option for practitioners in time-limited settings, pending confirmation in larger trials. tDCS Mindfulness Patellofemoral pain syndrome Balance athletes Figures Figure 1 Introduction Imagine a player who lands perfectly in practice, but during warm-up single-leg hops in a noisy arena, a dull burning around the kneecap suddenly flares up, causing a moment of doubt. That sensation is patellofemoral pain syndrome (PFPS), a common, load-sensitive condition of the patellofemoral joint among athletes, accounting for about 25–30% of sports-related injuries and up to 40% of knee disorders (Alonazi et al., 2021 ). It typically presents as pain around or behind the patella during joint-loading activities such as squatting, jumping, and landing (Collins et al., 2018 ). More than discomfort, patellofemoral pain has been associated with abnormal motor control and disturbed proprioception, which may impair postural control and muscle activation timing; changes that can undermine single-leg balance and turn a confident landing into a cautious one (Nunes et al., 2022 ). With no substitution available and kick-off imminent, the warm-up becomes a narrow window for a brief precompetition intervention that could steady balance and ease knee pain, helping protect performance. To meet this need, we selected two low burden adjuncts, transcranial direct current stimulation (tDCS) and mindfulness, based on prior studies and clinical precedent in PFPS. The first is tDCS, a noninvasive brain stimulation method that delivers a few milliamps of direct current through scalp electrodes to modulate cortical excitability. Polarity and electrode placement determine the effect, allowing subtle and often imperceptible shifts in motor or cognitive output (Birbaumer, 2024 ). tDCS modulates cortical excitability and has improved pain and function in other chronic musculoskeletal conditions (e.g., osteoarthritis, fibromyalgia, low back pain). Studies pairing tDCS with quadriceps strengthening report additive gains in pain and functional outcomes, supporting its plausible use as an adjunct for PFPS (Patra et al., 2025 ). The second is guided mindfulness, described as deliberate, present-focused, and nonjudgmental awareness that develops through intentional and consistent practice (Ghasem Kazem et al., 2025 ). Mindfulness may enhance PFPS-related sensorimotor function by increasing body-focused awareness and stabilizing attentional control, thereby improving joint-position sense, reducing attentional variability during dynamic tasks (Priore et al., 2023 ), and over time lowering chronic pain and associated functional interference (Wexler et al., 2024 ). Examining prior research on tDCS and mindfulness in PFPS highlights several representative studies. For example, Sharma et al. ( 2025 ) found that repeated tDCS added to a 6-week knee-strengthening program produced earlier and larger reductions in pain and disability in individuals with PFPS, whereas Ho et al. ( 2024 ) reported that a single session of bimodal tDCS paired with targeted exercise yielded no immediate, clinically significant changes in frontal-plane kinematics or pain in individuals with PFPS. An examination of mindfulness interventions for PFPS indicates that Bagheri et al. ( 2021 ) conducted a randomized, long-term (8-week) trial in female recreational runners and reported that the mindfulness adjunct produced more rapid clinical improvement and greater gains in knee function than exercise alone. Given these findings, tDCS and mindfulness have largely been evaluated separately in PFPS with mixed outcomes. Most positive effects derive from multi-session protocols; single-session neuromodulation has not produced immediate gains, and balance and pain intensity remain largely unexamined in athletes with PFPS. In parallel, combined tDCS and mindfulness protocols are increasingly applied in clinical settings and have shown additive benefits mainly for psychological outcomes such as mood (Alizadehgoradel, 2021 ), depression and anxiety (Brooks et al., 2021 ) and selective attention (Yavari Kateb et al., 2025 ). This combined protocol has been tested only rarely in musculoskeletal pain conditions, most notably in fibromyalgia, and to our knowledge, has not been applied to PFPS (Ramasawmy et al., 2022 ). Because athletes have limited time before competition and require rapid, we selected a short combined tDCS and brief guided mindfulness protocol. This approach is portable and easy to implement, and our goal is to determine whether it can produce rapid, transient improvements in postural control and pain intensity, making it potentially suitable for sideline or pre-game use. Therefore, this study evaluates whether a single 20-minute session combining tDCS and brief guided mindfulness produces improvements in single-leg balance and pain intensity in athletes with PFPS. Materials and Methods Participants This investigation was conceived as a pilot to assess feasibility and obtain preliminary variance/effect-size estimates for a subsequent definitive trial. Given the single-session within-subject crossover design, a cohort of n = 10 athletes was considered appropriate to detect the direction of effects while minimizing participant burden (Hertzog, 2008 ) Accordingly, ten athletes (5 women and 5 men) aged 19–27 years with PFPS were recruited from the Faculty of Sport Sciences and Health, university of Tehran, using convenience sampling. Sports represented were football, volleyball, basketball, badminton, running, and swimming. Eligibility was screened with a brief specialist-designed questionnaire querying insidious onset anterior or retropatellar knee pain for ≥ 6 weeks and pain provoked by at least two knee-loading activities (squatting, running, hopping, stair walking). Those meeting criteria attended an in-person clinical assessment by a specialist to confirm PFPS and exclude ineligible cases. Individuals with current or past psychiatric or neurological disorders were excluded. All participants provided written informed consent. Design and Procedure In this pilot study, we used a quasi-experimental, sham-controlled, single-session crossover design with a one-week washout between active and sham sessions to minimize carryover and allow neuromodulatory and mindfulness effects to subside (Zarzycki et al., 2025 ). Participants were randomized to one of two counterbalanced sequences: tDCS-Mindfulness followed by sham-mindfulness, or sham-mindfulness followed by tDCS-Mindfulness. Pretest and posttest measurements were obtained immediately before and immediately after each session. Static and dynamic balance were assessed using the Biodex Balance System (BBS), and pain intensity was measured with a Visual Analogue Scale (VAS) (Fig. 1). To control for acute confounders, participants were instructed to refrain from strenuous exercise and to avoid analgesic medication for 48 hours prior to testing (Rathleff et al., 2017 ). Measures Biodex Balance System (BBS) Static and dynamic single-leg balance tests on the limb affected by PFPS were performed and evaluated using BBS. Static testing used platform level 8, while dynamic testing involved progressively decreasing stability from level 8 to level 4. Participants stood barefoot with knees slightly flexed, hands on their chest, eyes open, and the non-weight-bearing limb held behind the weight-bearing limb; they were instructed to keep the platform as neutral as possible within the smallest concentric ring. Each trial lasted 30 seconds and there were 10 seconds of rest between trials during which the contralateral foot was placed on the floor to prevent fatigue. Three single-leg trials were performed on the affected limb, and the best score across trials was used for analysis. The BBS software provided three indices: 1. Anterior-posterior (AP) index, 2. medial/lateral (ML) index, and 3. overall index (Kim et al., 2022 ). Visual Analogue Scale (VAS) Scale Pain intensity was assessed using a numeric rating scale from 0 to 10, where 0 equals no pain and 10 equals the worst possible pain, as well as a 10 cm VAS presented as a visual anchor. The patellar palpation standard test was applied before and after the intervention to provoke pain, and participants were asked to rate their pain intensity on the 0 to 10 scale (Chamorro-Moriana et al., 2024 ). tDCS-Mindfulness Protocol The tDCS device used in the present study was the Active DAS system. To begin the training sessions for the tDCS-Mindfulness group, participants received 2 mA transcranial direct current stimulation (tDCS), with the anodal electrode placed at C3 according to the international 10–20 system, while simultaneously listening to pre-recorded audio files played on mobile phones through high-quality headphones. This protocol was selected based on de Moura et al. ( 2019 ) to target the primary motor cortex using C3 as an approximation of left M1 modulation of postural control. Stimulation duration and intensity were adopted from Ho et al. ( 2024 ), which demonstrated feasibility and tolerability in a comparable cohort. This single-session intervention was delivered using 5 x 5 cm square sponge pads, with the cathode electrode placed over the left supraorbital for a duration of 20 minutes. In the Sham-Mindfulness group, all conditions mirrored those of the tDCS-Mindfulness group, but the electric current was discontinued after 30 seconds without informing the participant. The combined tDCS-mindfulness protocol was adopted from Yavari Kateb et al. ( 2025 ), with the number of sessions reduced to a single session in the present study Statistical Analysis The data were analyzed using the following statistical methods: The Shapiro-Wilk test was conducted to assess the normality of the data. Descriptive statistics, such as mean and standard deviation, were calculated for age (years), height (cm), weight (kg), and sport history (years). The assumption of homogeneity of variances was tested using Levene’s test. We used ANCOVA to compare the two conditions (active vs. sham), entering the session-specific pretest as a covariate in both sessions. All statistical analyses were carried out using SPSS software version 24, with a significance level of α < 0.05. Results All 10 individuals enrolled successfully completed the study. Table 1 presents a summary of their demographic data. Table 1 Demographic characteristics of participants Group Variable N Minimum Maximum Mean SD Mindfulness-tDCS + Sham-tDCS Age (year) 10 19 27 21.50 2.718 Height (cm) 10 159 192 174.80 11.033 Weight (kg) 10 50 86 67.90 10.671 Sport History (year) 10 4 13 9.10 2.885 Table 2 summarizes the descriptive outcomes for static and dynamic balance assessments, along with VAS, presented separately for the pre-test and post-test evaluations. The table displays the descriptive statistics of static and dynamic balance, as well as VAS scores, across pre- and post-test phases for both tDCS-Mindfulness and Sham-Mindfulness groups. Overall, slight variations are observable between stages, particularly in VAS measures. Table 2 Descriptive statistics of the static and dynamic balance and VAS Group Variable Stages N M SD Mindfulness -tDCS Static balance Overall pre 10 1.220 .8324 post 10 1.410 .8171 Antero-Posterior pre 10 .720 .2898 post 10 .740 .2503 Medio-Lateral pre 10 .910 .7852 post 10 1.140 .8758 Dynamic balance Overall pre 10 1.480 1.4756 post 10 1.410 .7909 Antero-Posterior pre 10 .950 .7472 post 10 .720 .3190 Medio-Lateral pre 10 .980 1.2282 post 10 1.130 .8420 VAS pre 10 6.10 1.729 post 10 3.70 2.111 Sham-Mindfulness Static balance Overall pre 10 1.810 1.3270 post 10 1.950 1.5263 Antero-Posterior pre 10 .990 .8465 post 10 1.010 .7549 Medio-Lateral pre 10 1.340 .9663 post 10 1.560 1.2483 Dynamic balance Overall pre 10 1.560 1.0885 post 10 1.680 1.3710 Antero-Posterior pre 10 .700 .3944 post 10 .960 .8396 Medio-Lateral pre 10 1.390 1.05881.22 post 10 1.100 .9649 VAS pre 10 6.10 2.079 post 10 4.70 2.627 The Shapiro-Wilk test confirmed normal distribution, and Levene’s test showed homogeneity of variances (p > 0.05), allowing for ANCOVA to compare post-test scores between the two groups, with pre-test scores as covariates. Table 3 presents the comparison of post-test scores between the two groups. Between-group comparisons were conducted using ANCOVA, with pre-test scores entered as covariates. The analysis revealed significant differences in overall static balance (p = .038, η² = .336) and overall dynamic balance (p = .043, η² = .323) in favor of the active intervention group. Moreover, a highly significant effect was observed for VAS (p < .001, η² = .773), indicating a substantial reduction in perceived pain. No significant differences emerged in the AP and ML subcomponents. Table 3 Tests of Between-Subjects Effects Variable Sum of Squares df Mean Square F Sig Eta Squared Static Balance Overall 2.983 1 2.983 5.563 .038 * .336 Antero-Posterior .161 1 .161 1.982 .187 .153 Medio-Lateral 1.793 1 1.793 4.101 .068 .272 Dynamic Balance Overall .554 1 .554 5.238 .043 * .323 Antero-Posterior .087 1 .087 .689 .424 .059 Medio-Lateral .266 1 .266 3.550 .086 .244 VAS 46.038 1 46.038 37.366 .000 * .773 * Significant difference P < 0.05. Discussion This study evaluated the effects of a single session of combined tDCS and mindfulness intervention on static and dynamic balance, and on pain intensity, in athletes with PFPS. A sham-controlled study was designed using a brief 20-minute training procedure. The tDCS-Mindfulness condition produced significant improvements in overall static and dynamic balance compared with Sham-Mindfulness condition, but these benefits did not extend to the directional subcomponents AP and ML. Notably, pain intensity was significantly reduced following the active intervention. Although no prior studies have examined the exact combined tDCS and mindfulness protocol in PFPS, the broader literature on standalone tDCS, mindfulness, and combined tDCS protocols in lower limb conditions, despite differences in protocols, session numbers, and assessment tools, provides valuable context for interpreting our findings and motivates the comparisons that follow. In the domain of single interventions, several studies have examined the effects of tDCS and of mindfulness separately on balance. Notably, the acute improvements in overall static and dynamic balance observed in our study are partially consistent with those reported by Giancatarina et al. ( 2024 ). That study reported direction-specific reductions in Center of Pressure )CoP( measures notably along the antero-posterior axis, whereas our effects were restricted to overall balance (Giancatarina et al., 2024 ). Furthermore, Tohidirad et al. ( 2023 ) reported no significant between-group difference in the injured-leg CoP Y-axis after 10 sessions, while significant effects were observed for overall CoP at one-month follow-up in athletes with ACL injury, aligning with our finding of significant improvements only in overall balance. Another study showed that the use of tDCS and biofeedback improved proprioception and functional balance in the injured knee of athletes with ACL-deficiency (Jamebozorgi et al., 2023 ). The results of this study were aligned with our findings, particularly in terms of balance, despite differences in the number of sessions, protocol type, and assessment tools. A study on patellofemoral pain in female recreational runners, incorporating eight sessions of mindfulness, demonstrated improvements in knee function potentially linked to balance, suggesting the positive effects of mindfulness on this syndrome (Bagheri et al., 2021 ). This aligns indirectly with our findings, where mindfulness was also a key component of our intervention for PFPS. Examining combined tDCS interventions provides a valuable framework for interpreting and comparing our findings. For instance, a randomized controlled trial conducted in athletes with chronic ankle instability found that a single session of motor imagery combined with anodal tDCS over the DLPFC (F3) immediately improved both overall and directional (AP/ML) static and dynamic balance compared with Sham-Mindfulness group (Moghadas Tabrizi et al.). This stronger improvement in directional balance may reflect motor imagery’s ability to specifically activate motor networks, enhance internal motor planning, and rapidly prime sensorimotor pathways, leading to more effective postural adjustments (Nicholson et al., 2019 ). A combined study with tDCS and balance training improved anticipatory postural adjustments during gait initiation in individuals with chronic ankle instability, showing better CoP displacement and velocity. No significant differences were found between groups in the anterior-posterior direction. Despite differences in session numbers, stimulation areas, and dependent variables, both studies highlight that combined tDCS protocols can improve postural control (Beyraghi et al., 2025 ). These findings keep the outlook promising, although further well-designed studies are needed to confirm efficacy and define optimal protocols for clinical use. More importantly, why did the interventions improve overall static and dynamic balance significantly but not AP and ML? This likely reflects the task specific nature of balance adaptation, where muscle synergies and sensory weighting vary by plane and axis specific gains require practice that directly loads that plane (Giboin et al., 2015 ). Furthermore, while a single session of tDCS may lead to some neuroplastic changes, long-term effects require more sessions (Vestring et al., 2024 ). This likely explains why no significant improvements were observed in AP and ML balance, with only overall balance showing meaningful progress. These findings suggest that a single session of tDCS-Mindfulness can provide some improvements in balance for athletes with PFPS. While the short duration of the intervention limits its effects, it could still be a valuable tool in the early stages of rehabilitation or high-pressure situations. In addition, this protocol also showed potential benefits for reducing pain intensity. Despite differences in session number and protocol, Sharma et al. ( 2025 ) reported that 18 sessions of tDCS combined with knee strengthening produced significant pain reduction in individuals with PFPS, and Martorella et al. ( 2022 ) found similar analgesic effects in knee osteoarthritis. These studies are consistent with our finding that a single session of tDCS produced significant pain reduction in athletes with PFPS. Conversely, the study by Ramasawmy et al. ( 2022 ) used tDCS combined with mindfulness meditation over 10 sessions, but showed no significant improvement in pain intensity, which differs from the results observed in our study. This difference may be explained by the longer duration of their intervention, which could have caused more mental fatigue, while a single session in our study likely involved less strain. Additionally, the different types of conditions (fibromyalgia vs. PFPS) could have contributed to the variation in outcomes, though further studies are needed to confirm this. One possible explanation for the findings is that tDCS may enhance endogenous pain modulation, leading to immediate pain reduction even after a single session. This is consistent with Toufexis et al. ( 2023 ), who showed that tDCS over the DLPFC (F3) enhances pain modulation. While the current study focused on C3, it follows the same mechanism of tDCS-induced pain modulation Furthermore, the combination of mindfulness with tDCS may have acted synergistically to reduce pain. Mindfulness significantly reduces both the intensity and unpleasantness of pain, likely by increasing activity in brain regions responsible for pain regulation, such as the anterior cingulate cortex (Calderone et al., 2024 ). Even in the Sham-Mindfulness group, pain dropped noticeably with mindfulness alone, underscoring a likely mindfulness effect, although a tDCS placebo effect may also have contributed. Another plausible explanation is that mindfulness training modulates central pain processing, thereby increasing pain tolerance and reducing musculoskeletal pain (Cruze & Games, 2021 ). While the observed pain reduction after a single-session intervention is promising, these results should be interpreted with caution. The complexity of pain modulation suggests multiple contributing factors, and further research is needed to confirm these findings and understand the mechanisms. This study had several limitations. First, the small pilot sample (n = 10) limits statistical power and generalizability; findings should be interpreted as preliminary. Second, individual variability in responses to tDCS, mindfulness, and potential learning effects may have influenced outcomes despite the crossover and washout. Finally, the VAS, while practical, may not fully capture the complexity of pain and is susceptible to mood and cognitive bias. Encouraged by these results, we suggest that a single 20-minute session of combined tDCS and mindfulness on C3 could be an effective and practical intervention for improving overall static and dynamic balance and reducing pain intensity in athletes with PFPS. However, the intervention did not result in significant improvements in static and dynamic balance in the AP and ML directions. Future research could investigate how this technique can be applied to various rehabilitation factors, such as strength, mobility, and proprioception, to improve recovery and functional outcomes in athletes with PFPS and other musculoskeletal syndromes. Practitioners could consider using this protocol in time-limited situations, such as pre-competition or during brief rehabilitation sessions, to help reduce pain and improve overall balance in athletes with PFPS, though the effects may vary across different balance components. Declarations Conflict of interest The authors declare that they have no conflicts of interest. Ethical approval This study was approved by the Ethics Committee of the University of Tehran, under approval number IR.UT.SPORT.REC.1403.092. Informed consent Informed consent was obtained from all participants included in the study. Funding This research was financially supported by the University of Tehran (Grant No.: 25208/1/05). Author Contribution Y.M.T: Conceptualized the study, supervised the project, and oversaw intervention implementation. M.E: Conceptualized the study, collected data, and drafted the manuscript. Z.M: Collected data and prepared the dataset for analysis. M.Y.K: Performed statistical analyses and interpreted the results. N.K: Provided resources, materials, and equipment. All authors critically revised and approved the final manuscript. 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PloS one , 12 (12), e0188930. https://doi.org/10.1371/journal.pone.0188930 Sharma, M., Patra, R. C., & Govindappa, S. C. (2025). Effectiveness of transcranial direct electrical stimulation in management of patellofemoral pain syndrome: A randomized controlled trial. Journal of Family and Community Medicine , 32 (3), 223–230. 10.4103/jfcm.jfcm_296_24 Tohidirad, Z., Ehsani, F., Bagheri, R., & Jaberzadeh, S. (2023). Priming effects of anodal transcranial direct current stimulation on the effects of conventional physiotherapy on balance and muscle performance in athletes with anterior cruciate ligament injury. Journal of Sport Rehabilitation , 32 (3), 315–324. https://doi.org/10.1123/jsr.2022-0188 Toufexis, C., Macgregor, M., Lewis, A., & Flood, A. (2023). The effects of high-definition transcranial direct current stimulation on pain modulation and stress-induced hyperalgesia. British Journal of Pain , 17 (3), 244–254. https://doi.org/10.1177/20494637221150333 Vestring, S., Wolf, E., Dinkelacker, J., Frase, S., Hessling-Zeinen, C., Insan, S., Kumlehn, M. M., Feige, B., Domschke, K., & Normann, C. (2024). Lasting effects of transcranial direct current stimulation on the inducibility of synaptic plasticity by paired-associative stimulation in humans. Journal of NeuroEngineering and Rehabilitation , 21 (1), 162. https://doi.org/10.1186/s12984-024-01459-x Wexler, R. S., Fox, D. J., ZuZero, D., Bollen, M., Parikshak, A., Edmond, H., Lemau, J., Montenegro, D., Ramirez, J., & Kwin, S. (2024). Virtually delivered Mindfulness-Oriented Recovery Enhancement (MORE) reduces daily pain intensity in patients with lumbosacral radiculopathy: a randomized controlled trial. Pain Reports , 9 (2), e1132. 10.1097/PR9.0000000000001132 Yavari Kateb, M., Arabameri, E., Rostami, R., Zandi, G., H., & Moghadas Tabrizi, Y. (2025). The effects of a tDCS-mindfulness program on selective attention in skilled badminton players. Sport Sciences and Health Research , 17 (1), 55–68. https://doi.org/10.22059/sshr.2024.377254.1143 Zarzycki, R., Leung, A., Abraham, R., Hammoud, S., Perrone, M., & Kantak, S. (2025). Determining the safety, feasibility, and effects of anodal transcranial direct current stimulation on corticospinal excitability and quadriceps performance after anterior cruciate ligament reconstruction: a randomized crossover design. Annals of Joint , 10 , 3. https://doi.org/10.21037/aoj-24-15 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7801576","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":534919334,"identity":"e705f7c1-efa2-4473-8c6b-d6955600ad48","order_by":0,"name":"Masoud Esmaeilnejad","email":"","orcid":"","institution":"University of Tehran","correspondingAuthor":false,"prefix":"","firstName":"Masoud","middleName":"","lastName":"Esmaeilnejad","suffix":""},{"id":534919335,"identity":"030a0ca0-e7c2-444e-8159-9699840a1aed","order_by":1,"name":"Fatemeh Zahra Maleki Gohar","email":"","orcid":"","institution":"University of 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12:29:26","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":129754,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7801576/v1/ee0e55777e3cd2b47da22505.html"},{"id":94665829,"identity":"bba30c0c-7723-4035-9cdf-9e9a231cfff8","added_by":"auto","created_at":"2025-10-29 12:29:26","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":264568,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic overview of the pilot study design and procedures\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7801576/v1/94a3cf1a823473be91707984.png"},{"id":97135352,"identity":"bc3dd94b-86c1-40f3-bad6-b754f73138fe","added_by":"auto","created_at":"2025-12-01 09:36:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1013911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7801576/v1/ffa5c9a9-c720-4829-a2e1-0c1e521b8348.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Potential Synergistic Effects of Single-Session tDCS and Guided Mindfulness on Balance and Pain in Athletes with Patellofemoral Pain: A Pilot Crossover Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eImagine a player who lands perfectly in practice, but during warm-up single-leg hops in a noisy arena, a dull burning around the kneecap suddenly flares up, causing a moment of doubt. That sensation is patellofemoral pain syndrome (PFPS), a common, load-sensitive condition of the patellofemoral joint among athletes, accounting for about 25\u0026ndash;30% of sports-related injuries and up to 40% of knee disorders (Alonazi et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). It typically presents as pain around or behind the patella during joint-loading activities such as squatting, jumping, and landing (Collins et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). More than discomfort, patellofemoral pain has been associated with abnormal motor control and disturbed proprioception, which may impair postural control and muscle activation timing; changes that can undermine single-leg balance and turn a confident landing into a cautious one (Nunes et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). With no substitution available and kick-off imminent, the warm-up becomes a narrow window for a brief precompetition intervention that could steady balance and ease knee pain, helping protect performance.\u003c/p\u003e\u003cp\u003eTo meet this need, we selected two low burden adjuncts, transcranial direct current stimulation (tDCS) and mindfulness, based on prior studies and clinical precedent in PFPS. The first is tDCS, a noninvasive brain stimulation method that delivers a few milliamps of direct current through scalp electrodes to modulate cortical excitability. Polarity and electrode placement determine the effect, allowing subtle and often imperceptible shifts in motor or cognitive output (Birbaumer, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). tDCS modulates cortical excitability and has improved pain and function in other chronic musculoskeletal conditions (e.g., osteoarthritis, fibromyalgia, low back pain). Studies pairing tDCS with quadriceps strengthening report additive gains in pain and functional outcomes, supporting its plausible use as an adjunct for PFPS (Patra et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). The second is guided mindfulness, described as deliberate, present-focused, and nonjudgmental awareness that develops through intentional and consistent practice (Ghasem Kazem et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Mindfulness may enhance PFPS-related sensorimotor function by increasing body-focused awareness and stabilizing attentional control, thereby improving joint-position sense, reducing attentional variability during dynamic tasks (Priore et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and over time lowering chronic pain and associated functional interference (Wexler et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExamining prior research on tDCS and mindfulness in PFPS highlights several representative studies. For example, Sharma et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) found that repeated tDCS added to a 6-week knee-strengthening program produced earlier and larger reductions in pain and disability in individuals with PFPS, whereas Ho et al. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) reported that a single session of bimodal tDCS paired with targeted exercise yielded no immediate, clinically significant changes in frontal-plane kinematics or pain in individuals with PFPS. An examination of mindfulness interventions for PFPS indicates that Bagheri et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) conducted a randomized, long-term (8-week) trial in female recreational runners and reported that the mindfulness adjunct produced more rapid clinical improvement and greater gains in knee function than exercise alone.\u003c/p\u003e\u003cp\u003eGiven these findings, tDCS and mindfulness have largely been evaluated separately in PFPS with mixed outcomes. Most positive effects derive from multi-session protocols; single-session neuromodulation has not produced immediate gains, and balance and pain intensity remain largely unexamined in athletes with PFPS. In parallel, combined tDCS and mindfulness protocols are increasingly applied in clinical settings and have shown additive benefits mainly for psychological outcomes such as mood (Alizadehgoradel, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), depression and anxiety (Brooks et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and selective attention (Yavari Kateb et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). This combined protocol has been tested only rarely in musculoskeletal pain conditions, most notably in fibromyalgia, and to our knowledge, has not been applied to PFPS (Ramasawmy et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Because athletes have limited time before competition and require rapid, we selected a short combined tDCS and brief guided mindfulness protocol. This approach is portable and easy to implement, and our goal is to determine whether it can produce rapid, transient improvements in postural control and pain intensity, making it potentially suitable for sideline or pre-game use.\u003c/p\u003e\u003cp\u003eTherefore, this study evaluates whether a single 20-minute session combining tDCS and brief guided mindfulness produces improvements in single-leg balance and pain intensity in athletes with PFPS.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants\u003c/h2\u003e\n\u003cp\u003eThis investigation was conceived as a pilot to assess feasibility and obtain preliminary variance/effect-size estimates for a subsequent definitive trial. Given the single-session within-subject crossover design, a cohort of n\u0026thinsp;=\u0026thinsp;10 athletes was considered appropriate to detect the direction of effects while minimizing participant burden (Hertzog, \u003cspan class=\"CitationRef\"\u003e2008\u003c/span\u003e)\u003c/p\u003e\n\u003cp\u003eAccordingly, ten athletes (5 women and 5 men) aged 19\u0026ndash;27 years with PFPS were recruited from the Faculty of Sport Sciences and Health, university of Tehran, using convenience sampling. Sports represented were football, volleyball, basketball, badminton, running, and swimming. Eligibility was screened with a brief specialist-designed questionnaire querying insidious onset anterior or retropatellar knee pain for \u0026ge;\u0026thinsp;6 weeks and pain provoked by at least two knee-loading activities (squatting, running, hopping, stair walking). Those meeting criteria attended an in-person clinical assessment by a specialist to confirm PFPS and exclude ineligible cases. Individuals with current or past psychiatric or neurological disorders were excluded. All participants provided written informed consent.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eDesign and Procedure\u003c/h3\u003e\n\u003cp\u003eIn this pilot study, we used a quasi-experimental, sham-controlled, single-session crossover design with a one-week washout between active and sham sessions to minimize carryover and allow neuromodulatory and mindfulness effects to subside (Zarzycki et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). Participants were randomized to one of two counterbalanced sequences: tDCS-Mindfulness followed by sham-mindfulness, or sham-mindfulness followed by tDCS-Mindfulness. Pretest and posttest measurements were obtained immediately before and immediately after each session. Static and dynamic balance were assessed using the Biodex Balance System (BBS), and pain intensity was measured with a Visual Analogue Scale (VAS) (Fig.\u0026nbsp;1). To control for acute confounders, participants were instructed to refrain from strenuous exercise and to avoid analgesic medication for 48 hours prior to testing (Rathleff et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eBiodex Balance System (BBS)\u003c/h2\u003e\n\u003cp\u003eStatic and dynamic single-leg balance tests on the limb affected by PFPS were performed and evaluated using BBS. Static testing used platform level 8, while dynamic testing involved progressively decreasing stability from level 8 to level 4. Participants stood barefoot with knees slightly flexed, hands on their chest, eyes open, and the non-weight-bearing limb held behind the weight-bearing limb; they were instructed to keep the platform as neutral as possible within the smallest concentric ring. Each trial lasted 30 seconds and there were 10 seconds of rest between trials during which the contralateral foot was placed on the floor to prevent fatigue. Three single-leg trials were performed on the affected limb, and the best score across trials was used for analysis. The BBS software provided three indices: 1. Anterior-posterior (AP) index, 2. medial/lateral (ML) index, and 3. overall index (Kim et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eVisual Analogue Scale (VAS) Scale\u003c/h3\u003e\n\u003cp\u003ePain intensity was assessed using a numeric rating scale from 0 to 10, where 0 equals no pain and 10 equals the worst possible pain, as well as a 10 cm VAS presented as a visual anchor. The patellar palpation standard test was applied before and after the intervention to provoke pain, and participants were asked to rate their pain intensity on the 0 to 10 scale (Chamorro-Moriana et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003etDCS-Mindfulness Protocol\u003c/h2\u003e\n\u003cp\u003eThe tDCS device used in the present study was the Active DAS system. To begin the training sessions for the tDCS-Mindfulness group, participants received 2 mA transcranial direct current stimulation (tDCS), with the anodal electrode placed at C3 according to the international 10\u0026ndash;20 system, while simultaneously listening to pre-recorded audio files played on mobile phones through high-quality headphones. This protocol was selected based on de Moura et al. (\u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e) to target the primary motor cortex using C3 as an approximation of left M1 modulation of postural control. Stimulation duration and intensity were adopted from Ho et al. (\u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e), which demonstrated feasibility and tolerability in a comparable cohort. This single-session intervention was delivered using 5 x 5 cm square sponge pads, with the cathode electrode placed over the left supraorbital for a duration of 20 minutes.\u003c/p\u003e\n\u003cp\u003eIn the Sham-Mindfulness group, all conditions mirrored those of the tDCS-Mindfulness group, but the electric current was discontinued after 30 seconds without informing the participant. The combined tDCS-mindfulness protocol was adopted from Yavari Kateb et al. (\u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e), with the number of sessions reduced to a single session in the present study\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\n\u003cp\u003eThe data were analyzed using the following statistical methods: The Shapiro-Wilk test was conducted to assess the normality of the data. Descriptive statistics, such as mean and standard deviation, were calculated for age (years), height (cm), weight (kg), and sport history (years). The assumption of homogeneity of variances was tested using Levene\u0026rsquo;s test. We used ANCOVA to compare the two conditions (active vs. sham), entering the session-specific pretest as a covariate in both sessions. All statistical analyses were carried out using SPSS software version 24, with a significance level of \u0026alpha;\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eAll 10 individuals enrolled successfully completed the study. Table\u0026nbsp;1 presents a summary of their demographic data.\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" style=\"width: 466px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable\u0026nbsp;1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic characteristics of participants\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 124.236px;\" colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 111.634px;\" align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 12.3657px;\" align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003eMinimum\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003eMaximum\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003eMean\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003eSD\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 124.236px;\" colspan=\"2\" rowspan=\"4\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMindfulness-tDCS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026thinsp;+\u0026thinsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSham-tDCS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 111.634px;\" align=\"left\"\u003e\n\u003cp\u003eAge (year)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.3657px;\" align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e21.50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e2.718\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 111.634px;\" align=\"left\"\u003e\n\u003cp\u003eHeight (cm)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.3657px;\" align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e159\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e192\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e174.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e11.033\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 111.634px;\" align=\"left\"\u003e\n\u003cp\u003eWeight (kg)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.3657px;\" align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e86\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e67.90\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e10.671\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 111.634px;\" align=\"left\"\u003e\n\u003cp\u003eSport History (year)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 12.3657px;\" align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e9.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 38px;\" align=\"left\"\u003e\n\u003cp\u003e2.885\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003eTable 2 summarizes the descriptive outcomes for static and dynamic balance assessments, along with VAS, presented separately for the pre-test and post-test evaluations. The table displays the descriptive statistics of static and dynamic balance, as well as VAS scores, across pre- and post-test phases for both tDCS-Mindfulness and Sham-Mindfulness groups. Overall, slight variations are observable between stages, particularly in VAS measures.\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDescriptive statistics of the static and dynamic balance and VAS\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eGroup\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStages\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSD\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"14\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eMindfulness -tDCS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStatic balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.220\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8324\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.410\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8171\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.720\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.2898\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.740\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.2503\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.910\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.7852\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.140\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8758\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDynamic balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.480\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.4756\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.410\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.7909\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.950\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.7472\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.720\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.3190\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.980\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2282\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.130\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8420\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVAS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.729\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.111\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"14\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSham-Mindfulness\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStatic balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.810\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.3270\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.950\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.5263\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.990\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8465\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.7549\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.340\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.9663\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.560\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2483\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"6\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDynamic balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.560\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.0885\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.680\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.3710\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.700\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.3944\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.960\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.8396\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.390\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.05881.22\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.100\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.9649\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVAS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epre\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.079\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003epost\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.627\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\n\u003cp\u003eThe Shapiro-Wilk test confirmed normal distribution, and Levene\u0026rsquo;s test showed homogeneity of variances (p \u0026gt; 0.05), allowing for ANCOVA to compare post-test scores between the two groups, with pre-test scores as covariates. Table 3 presents the comparison of post-test scores between the two groups. Between-group comparisons were conducted using ANCOVA, with pre-test scores entered as covariates. The analysis revealed significant differences in overall static balance (p = .038, \u0026eta;\u0026sup2; = .336) and overall dynamic balance (p = .043, \u0026eta;\u0026sup2; = .323) in favor of the active intervention group. Moreover, a highly significant effect was observed for VAS (p \u0026lt; .001, \u0026eta;\u0026sup2; = .773), indicating a substantial reduction in perceived pain. No significant differences emerged in the AP and ML subcomponents.\u003c/p\u003e\n\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eTests of Between-Subjects Effects\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSum of Squares\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003edf\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMean Square\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSig\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEta Squared\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eStatic Balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.983\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.983\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.563\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.038\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.336\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.161\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.161\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.982\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.187\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.153\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.793\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.793\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.101\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.068\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.272\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDynamic Balance\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOverall\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.554\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.554\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.238\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.043\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.323\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAntero-Posterior\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.087\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.087\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.689\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.424\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.059\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedio-Lateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.266\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.266\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.550\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.086\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.244\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.038\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.038\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37.366\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.000\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.773\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\" align=\"left\"\u003e\n\u003cp\u003e* Significant difference P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the effects of a single session of combined tDCS and mindfulness intervention on static and dynamic balance, and on pain intensity, in athletes with PFPS. A sham-controlled study was designed using a brief 20-minute training procedure. The tDCS-Mindfulness condition produced significant improvements in overall static and dynamic balance compared with Sham-Mindfulness condition, but these benefits did not extend to the directional subcomponents AP and ML. Notably, pain intensity was significantly reduced following the active intervention.\u003c/p\u003e\u003cp\u003eAlthough no prior studies have examined the exact combined tDCS and mindfulness protocol in PFPS, the broader literature on standalone tDCS, mindfulness, and combined tDCS protocols in lower limb conditions, despite differences in protocols, session numbers, and assessment tools, provides valuable context for interpreting our findings and motivates the comparisons that follow.\u003c/p\u003e\u003cp\u003eIn the domain of single interventions, several studies have examined the effects of tDCS and of mindfulness separately on balance. Notably, the acute improvements in overall static and dynamic balance observed in our study are partially consistent with those reported by Giancatarina et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). That study reported direction-specific reductions in Center of Pressure )CoP( measures notably along the antero-posterior axis, whereas our effects were restricted to overall balance (Giancatarina et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Furthermore, Tohidirad et al. (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) reported no significant between-group difference in the injured-leg CoP Y-axis after 10 sessions, while significant effects were observed for overall CoP at one-month follow-up in athletes with ACL injury, aligning with our finding of significant improvements only in overall balance. Another study showed that the use of tDCS and biofeedback improved proprioception and functional balance in the injured knee of athletes with ACL-deficiency (Jamebozorgi et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The results of this study were aligned with our findings, particularly in terms of balance, despite differences in the number of sessions, protocol type, and assessment tools. A study on patellofemoral pain in female recreational runners, incorporating eight sessions of mindfulness, demonstrated improvements in knee function potentially linked to balance, suggesting the positive effects of mindfulness on this syndrome (Bagheri et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This aligns indirectly with our findings, where mindfulness was also a key component of our intervention for PFPS.\u003c/p\u003e\u003cp\u003eExamining combined tDCS interventions provides a valuable framework for interpreting and comparing our findings. For instance, a randomized controlled trial conducted in athletes with chronic ankle instability found that a single session of motor imagery combined with anodal tDCS over the DLPFC (F3) immediately improved both overall and directional (AP/ML) static and dynamic balance compared with Sham-Mindfulness group (Moghadas Tabrizi et al.). This stronger improvement in directional balance may reflect motor imagery\u0026rsquo;s ability to specifically activate motor networks, enhance internal motor planning, and rapidly prime sensorimotor pathways, leading to more effective postural adjustments (Nicholson et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A combined study with tDCS and balance training improved anticipatory postural adjustments during gait initiation in individuals with chronic ankle instability, showing better CoP displacement and velocity. No significant differences were found between groups in the anterior-posterior direction. Despite differences in session numbers, stimulation areas, and dependent variables, both studies highlight that combined tDCS protocols can improve postural control (Beyraghi et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). These findings keep the outlook promising, although further well-designed studies are needed to confirm efficacy and define optimal protocols for clinical use.\u003c/p\u003e\u003cp\u003eMore importantly, why did the interventions improve overall static and dynamic balance significantly but not AP and ML? This likely reflects the task specific nature of balance adaptation, where muscle synergies and sensory weighting vary by plane and axis specific gains require practice that directly loads that plane (Giboin et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Furthermore, while a single session of tDCS may lead to some neuroplastic changes, long-term effects require more sessions (Vestring et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This likely explains why no significant improvements were observed in AP and ML balance, with only overall balance showing meaningful progress. These findings suggest that a single session of tDCS-Mindfulness can provide some improvements in balance for athletes with PFPS. While the short duration of the intervention limits its effects, it could still be a valuable tool in the early stages of rehabilitation or high-pressure situations.\u003c/p\u003e\u003cp\u003eIn addition, this protocol also showed potential benefits for reducing pain intensity. Despite differences in session number and protocol, Sharma et al. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2025\u003c/span\u003e) reported that 18 sessions of tDCS combined with knee strengthening produced significant pain reduction in individuals with PFPS, and Martorella et al. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) found similar analgesic effects in knee osteoarthritis. These studies are consistent with our finding that a single session of tDCS produced significant pain reduction in athletes with PFPS. Conversely, the study by Ramasawmy et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) used tDCS combined with mindfulness meditation over 10 sessions, but showed no significant improvement in pain intensity, which differs from the results observed in our study. This difference may be explained by the longer duration of their intervention, which could have caused more mental fatigue, while a single session in our study likely involved less strain. Additionally, the different types of conditions (fibromyalgia vs. PFPS) could have contributed to the variation in outcomes, though further studies are needed to confirm this.\u003c/p\u003e\u003cp\u003eOne possible explanation for the findings is that tDCS may enhance endogenous pain modulation, leading to immediate pain reduction even after a single session. This is consistent with Toufexis et al. (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), who showed that tDCS over the DLPFC (F3) enhances pain modulation. While the current study focused on C3, it follows the same mechanism of tDCS-induced pain modulation Furthermore, the combination of mindfulness with tDCS may have acted synergistically to reduce pain. Mindfulness significantly reduces both the intensity and unpleasantness of pain, likely by increasing activity in brain regions responsible for pain regulation, such as the anterior cingulate cortex (Calderone et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Even in the Sham-Mindfulness group, pain dropped noticeably with mindfulness alone, underscoring a likely mindfulness effect, although a tDCS placebo effect may also have contributed. Another plausible explanation is that mindfulness training modulates central pain processing, thereby increasing pain tolerance and reducing musculoskeletal pain (Cruze \u0026amp; Games, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). While the observed pain reduction after a single-session intervention is promising, these results should be interpreted with caution. The complexity of pain modulation suggests multiple contributing factors, and further research is needed to confirm these findings and understand the mechanisms.\u003c/p\u003e\u003cp\u003eThis study had several limitations. First, the small pilot sample (n\u0026thinsp;=\u0026thinsp;10) limits statistical power and generalizability; findings should be interpreted as preliminary. Second, individual variability in responses to tDCS, mindfulness, and potential learning effects may have influenced outcomes despite the crossover and washout. Finally, the VAS, while practical, may not fully capture the complexity of pain and is susceptible to mood and cognitive bias.\u003c/p\u003e\u003cp\u003eEncouraged by these results, we suggest that a single 20-minute session of combined tDCS and mindfulness on C3 could be an effective and practical intervention for improving overall static and dynamic balance and reducing pain intensity in athletes with PFPS. However, the intervention did not result in significant improvements in static and dynamic balance in the AP and ML directions.\u003c/p\u003e\u003cp\u003eFuture research could investigate how this technique can be applied to various rehabilitation factors, such as strength, mobility, and proprioception, to improve recovery and functional outcomes in athletes with PFPS and other musculoskeletal syndromes.\u003c/p\u003e\u003cp\u003ePractitioners could consider using this protocol in time-limited situations, such as pre-competition or during brief rehabilitation sessions, to help reduce pain and improve overall balance in athletes with PFPS, though the effects may vary across different balance components.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003cp\u003e This study was approved by the Ethics Committee of the University of Tehran, under approval number IR.UT.SPORT.REC.1403.092.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003cp\u003e Informed consent was obtained from all participants included in the study.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research was financially supported by the University of Tehran (Grant No.: 25208/1/05).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eY.M.T: Conceptualized the study, supervised the project, and oversaw intervention implementation. M.E: Conceptualized the study, collected data, and drafted the manuscript. Z.M: Collected data and prepared the dataset for analysis. M.Y.K: Performed statistical analyses and interpreted the results. N.K: Provided resources, materials, and equipment. All authors critically revised and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlizadehgoradel, J. (2021). 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Determining the safety, feasibility, and effects of anodal transcranial direct current stimulation on corticospinal excitability and quadriceps performance after anterior cruciate ligament reconstruction: a randomized crossover design. \u003cem\u003eAnnals of Joint\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e, 3. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.21037/aoj-24-15\u003c/span\u003e\u003cspan address=\"10.21037/aoj-24-15\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"tDCS, Mindfulness, Patellofemoral pain syndrome, Balance, athletes","lastPublishedDoi":"10.21203/rs.3.rs-7801576/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7801576/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe objective of this study was to investigate the synergistic effect of a single-session combined transcranial direct current stimulation (tDCS) and mindfulness intervention on static and dynamic single-leg balance and pain intensity in athletes with patellofemoral pain syndrome (PFPS). Ten athletes with PFPS participated in a pilot randomized crossover study. Each participant received active tDCS-Mindfulness and Sham-Mindfulness in randomized order, with a one-week interval between sessions; participants were not informed of the condition. Both groups received a 20-minute intervention (anode over C3, 2 mA) while listening to brief guided mindfulness; in the Sham-Mindfulness group the current was discontinued after 30 seconds. Participants completed single-leg balance tests on the Biodex Balance System (BBS) and rated pain intensity on a 10-cm Visual Analogue Scale (VAS). Following initial assessments, covariance analysis was performed. Between-group comparisons showed that a single-session combined tDCS-Mindfulness produced improvements in overall static and dynamic single-leg balance and reduced pain intensity (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, the intervention did not demonstrate a synergistic effect on the AP and ML subcomponents of either static or dynamic balance (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This study suggests that a brief, tDCS-mindfulness intervention can confer modest, immediate improvements in balance and reduce pain in athletes with PFPS. This approach could represent a promising option for practitioners in time-limited settings, pending confirmation in larger trials.\u003c/p\u003e","manuscriptTitle":"Potential Synergistic Effects of Single-Session tDCS and Guided Mindfulness on Balance and Pain in Athletes with Patellofemoral Pain: A Pilot Crossover Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 12:29:21","doi":"10.21203/rs.3.rs-7801576/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32faa8b9-88ed-4cb2-9f92-9384f8696bfa","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-22T21:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 12:29:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7801576","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7801576","identity":"rs-7801576","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}