Effect of Anodal Transcranial Direct Current Stimulation on Balance in Children with Autism Spectrum Disorder

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Abubakr, Manal M. Mahdi Omar, Sara Ali, Dina Y. Elalfy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7321706/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Dec, 2025 Read the published version in Middle East Current Psychiatry → Version 1 posted 9 You are reading this latest preprint version Abstract Background: Autism spectrum disorder (ASD) is a neurodevelopmental delay condition. Although behavioural abnormalities are the primary indicators of the disorder, still a significant number of children with ASD present with motor abnormalities. Research has also identified deficiencies in their postural stability, and their gait patterns, which impaired their motor coordination. Transcranial direct current stimulation (tDCS) is a safe, accessible brain stimulation method, the impact of tDCS on the primary motor cortex during motor training, which demonstrated improvements in balance and motor skills in ASD children had been investigated. The present study seeks to examine the effect of anodal tDCS over the primary motor cortex on balance in patients with ASD Results: Both groups showed significant difference in MABC-2 balance subscale and QNST when baseline was compared to post-intervention and to the follow-up parameters. Both the post-intervention and follow-up balance subscale of MABC-2 and QNST were significantly higher in group I (who received tDCS sessions and neuro- rehabilitation program) compared to group II (who received rehabilitation program only). Similarly, the percentage of change from baseline to post-intervention and to 2- month follow-up of both MBC-2 balance subscale and QNST was significantly higher in group I in comparison to group II. In group I there was a positive correlation between the Quick Neurological Screening Test (QNST) and both childhood autism rating scale (CARS) scores and Vineland scores. In group II there was a negative correlation between the Movement Assessment Battery for Children-2 (MABC2) and CARS scores and a positive correlation between the MABC2 and Vineland. In both groups there was a negative correlation between MABC2 SD and BMI Conclusions: tDCS is a non- invasive new adjuvant therapeutic approach in ASD. The current study revealed that severe autistic symptoms are associated with greater motor deficits. Immediately after applying tDCS sessions alongside neurorebilitation program; balance subscales and neurological deficits improved significantly more than applying neurorebilitation program alone and this effect continued in the follow- up. Autism spectrum disorder transcranial direct current stimulation balance and motor skills Movement Assessment Battery for Children-2 Quick Neurological Screening Test Figures Figure 1 Figure 2 BACKGROUND Autism spectrum disorder (ASD) is a neurodevelopmental delay condition characterized by behavioural and adaptive functional abnormalities [ 1 ]. Although behavioural abnormalities are the primary indicators of the disorder, still a significant number of children with ASD present with motor abnormalities, and went through rehabilitation and balance-based exercises due to the adverse effects of motor control issues on their daily lives. Approximately 83% of children with ASD experience varying degrees of difficulty with gross and fine motor functions [ 2 ]. Research has also identified deficiencies in their postural stability, and their gait patterns, which impaired their motor coordination, led to presence of dyspraxia, and delay in the acquisition of their motor milestones and basic motor skills [ 3 ]. A persistent concern for individuals with ASD is standing balance, as many have not achieved the same level of balance as typically developing individuals. When comparing autistic children to their typically developing peers, the former demonstrate poor postural or balance control, evidenced by postural sway in both double-leg and single-leg stances. Maintaining proper balance is crucial for performing daily activities such as dressing, bathing, and engaging in recreational pursuits like sports and bicycling. Children with Autism Spectrum Disorder (ASD) may face challenges in participating in these social and recreational activities [ 4 ], which can negatively affect their social cognition, communication, and overall engagement. Furthermore, these difficulties hinder their ability to explore their environment, thereby impacting both social and motor development. In this population, such challenges may also contribute to social- communication disorders, including social isolation and anxiety [ 5 ]. 1 At the neuroanatomical level of individuals with ASD, exhibit abnormalities in the sub- cortical white matters connectivity and the cerebellum, also atypical connections in the frontal- striatal areas, due to impaired connectivity between the primary sensory areas and motor areas, and abnormalities in the frontal- parietal network, as evidenced increase of the volume and surface area of their gray matter. Neuro- functional impairments in this population include inadequate multisensory integration, impaired sensory input processing, and difficulties with self other mapping. These deficits are posited to underlie the variations in motor performance observed among children with ASD, supporting the hypothesis that transcranial direct current stimulation (tDCS) applied to motor cortical areas may enhance motor abilities in this clinical group [ 6 ]. Transcranial direct current stimulation (tDCS) is a safe, accessible brain stimulation method, considered to be non- invasive that employs surface electrodes to administer a low-intensity monophasic electrical current to the scalp. This technique induces long-lasting changes in cortical excitability [ 7 ]. The polarity of the current plays a crucial role in cortical regulation: cathodal stimulation exerts an inhibitory effect by hyperpolarizing the neuronal cell membrane, whereas anodal stimulation enhances the cortical excitability by promoting depolarization of the neuronal cell membrane [ 8 ]. Certain aspects of movement, such as strength, movement direction, speed, acceleration, are linked to the primary motor cortex. Numerous studies involving individuals across various life stages have employed anodal tDCS over this brain region to demonstrate that cortical modulation of neural networks can be facilitated. This modulation can enhance and support the learning and consolidation of motor patterns, particularly when stimulation is combined with motor training [ 9 ]. The impact of anodal tDCS over the left dorsolateral prefrontal cortex [ 10 ] [ 11 ] [ 12 ] [ 13 ] or the temporoparietal junction have predominantly been investigated in clinical trials involving autistic children. These studies aim to modulate dysfunctional areas directly associated with the disorder's core diagnostic characteristics, namely impaired executive functions and social communication. Previous trials have demonstrated a reduction in the severity of the disorder's symptoms, particularly concerning social and nonverbal communication, a decrease in stereotyped behaviours, and an enhancement in their working memory [ 14 , 15 ]. Currently, there exists only one clinical trial that investigates the impact of tDCS on the primary motor cortex during motor training, which demonstrated improvements in balance and motor skills in ASD children [ 6 ]. The present study seeks to examine the effect of anodal tDCS over the primary motor cortex on balance in patients with ASD. METHODOLOGY Participants: This study was conducted from July 2024 to July 2025, involving 60children diagnosed with ASD who were recruited from the outpatient clinic of the Special Needs Care Centre, Faculty of Postgraduate Childhood Studies, Ain Shams University. The participants adhered to the following criteria: Inclusion Criteria: Participants were aged between 6 and 17 years and were diagnosed with Autism Spectrum Disorder (ASD) in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [ 16 ]. Participants exhibited balance disorders, scoring at or below the 15th percentile on balance subscale of the Movement Assessment Battery for Children-2 (MABC-2) [ 17 ]. They demonstrated the ability to comprehend and communicate with motor training instructors and were capable of executing the prescribed motor learning instructions. There was no alteration in medication within the six months preceding the study or during its duration, and participants did not engage in other regular exercise programs. Exclusion Criteria: Individuals with a history of epilepsy or seizures, neurological or neuromuscular disorders or syndromes other than Autism Spectrum Disorder (ASD), those who have undergone orthopaedic or neurological surgery within 12 months prior to the intervention, or have had any neurosurgical procedures, as well as those with orthopaedic deformities requiring surgical intervention, metallic implants all over the body, or hearing devices, and those who might show difficulty in cooperation, and understanding the proposed activities needed in the present study. Randomization and Blinding: Following the selection of participants based on the established eligibility criteria and the completion of the pre-intervention assessment, randomization was executed by an independent statistician utilizing a 8 simple computer-generated randomization method. Participants were randomly allocated in a 1:1 ratio into two groups, each comprising 30 patients: the experimental ASD group and the control (sham) group. This study was conducted in a double-blind manner, ensuring that the investigators, participants, and their families were unaware of the participants' group assignments. The interventions were administered byan independent, trained physiotherapist who was not involved in this study. Sample Size: Utilizing the PASS 15 program for sample size calculation, an examination of results from a prior study (Mahmoodifar and Sotoodeh, 2020) [ 6 ] indicated that transcranial direct current stimulation (tDCS) significantly enhances motor skill training in children with autism spectrum disorder. Assuming an effect size difference of 0.7 between the two groups concerning the improvement in balance scores, and accounting for a 5% adjustment for dropout rate, a sample size of at least 30 patients per group is required to achieve 80% power to reject the null hypothesis of zero effect size. This calculation is based on a population effect size of 0.70 and a significance level (alpha) of 0.05, employing a one-sided two-sample equal-variance t-test. Assessment: 2 - All participants underwent comprehensive history taking and clinical examination, which included the assessment of ASD severity by applying the Childhood Autism Rating Scale (CARS). This scale comprises 14 domains evaluating autism behaviours, and a 15th domain assessing general impressions of autism. The total score ranges from 15 to 60, where a score of 30-36.5 indicates mild to moderate degree of autism, and a score of 37–60 signifies severe degree of autism [ 18 ]. Additionally, the adaptive behaviour of individuals with ASD was evaluated using the Vineland Adaptive Behaviour Scales, Second Edition (Vineland-II). This standardized assessment tool measures adaptive behaviour in individuals from birth to 90 years of age, assessing daily living skills, including social and practical abilities. It is widely utilized in clinical and educational settings to identify strengths and weaknesses, support diagnoses, and develop intervention plans. The total score ranges from 20 to 160, categorized as follows: Weak adaptive behaviour: 20–70, weak-average: 71–85, average: 86–114, average-high: 115–129, and high: 130–160 [ 19 ]. The primary outcome was evaluated using the balance subscale of the Movement Assessment Battery for Children-2 (MABC-2), a validated and reliable instrument for assessing and identifying impairments in individuals with ASD. This tool includes various tests tailored for distinct age groups: from 3–6 years, from 7–11 years, and from 12–17 years. The balance subscale comprises three items for each age category, consisting of two dynamic and one static test a child's raw score can be converted into an age-based standard score and percentile equivalent for each subscale. Percentiles serve as "Traffic Lights" to facilitate interpretation when communicating test results to caregivers and educators, with the following zones: (a) the Red zone: represents percentile scores at or below the 5th percentile, (b) the Amber zone: represents percentile scores between the 6th and 15th percentile, and (c) the Green zone: represents percentile scores above the 15th percentile. The balance subscale of the MABC-2 was administered at baseline, immediately following the intervention, and two months post-intervention. [ 17 ] The Quick Neurological Screening Test (QNST) was applied to assess the secondary outcome at three distinct time duration: baseline, immediately following the intervention, and two months post-intervention. The QNST is a concise, standardized instrument designed to evaluate neurological function, requiring approximately10-15 minutes for administration. It examines various dimensions of neurological function, including cranial nerves, motor function, sensory perception, and coordination. The scoring system categorizes results as follows: a normal score ranges from 0 to 25, a suspicious score from 26 to 50, and a pathological score is indicated by scores greater than 50 [ 20 ]. - Evaluation of Adverse Effects of tDCS: Subsequent to each session and during the follow-up period, participants and their families were queried regarding any side effects experienced as a result of the stimulation process. Intervention : - The transcranial direct current stimulation (tDCS) sessions were administered by a trained physiotherapist utilizing a Brain PremierE1 device (Shenzhen Yingcchi Technology Co, China). Round sponge electrodes with a diameter of five centimetres, soaked in saline, were employed to deliver the direct current. Group 1received stimulation of the left primary motor cortex (M1) (C3) via the anodal electrode of the tDCS, in accordance with the International System of Electrode Placement EEG 10–20 (Fig. 1); the cathodal electrode was positioned over the right supraorbital region (Fp2). The current parameters were as follows: duration of 20 minutes and an intensity of 1 mill ampere, with a30-second ramp-up and ramp-down. Conversely, Group 2received sham tDCS over the same area for the same duration (20minutes); however, the stimulator was deactivated after 30seconds to ensure participant blinding. Participants in each group attended 10 sessions of the respective intervention (5 sessions per week for 2 weeks). Participants who failed to attend at least 8sessions in total were excluded from the study [ 6 ]. Neurorehabilitation program Immediately following transcranial direct current stimulation (tDCS), all participated children of both groups were engaged in individualized exercises tailored to their performance on the balance subscale of the Movement Assessment Battery forChildren-2 (MABC-2). Each participant underwent 10 sessions, over two weeks with five sessions per week, each lasting 30 minutes. The exercises were designed to enhance both static and dynamic balance and included activities such as balance board exercises, Swiss ball exercises, balancing on one foot, walking on tiptoes, walking on a balance beam heel-to-toe both forward and backward, as well as jumping and hopping on one leg in both straight and zigzag patterns [ 6 ], [ 21 ]. RESULTS Demographic data and clinical characteristics: This study comprised 60 participants, including 51 males and 9 females, with ages ranging from 6 to 16 years. The mean Body Mass Index (BMI) of the participants was 20.95 ± 1.5. The mean Childhood Autism Rating Scale (CARS) score was 35.73 ± 6.26, while the mean Vineland Adaptive Behaviour Scales score was 111.9 ± 20.94. No statistically significant differences were observed in the aforementioned parameters between the two groups under study (Table 1 ). Table 1 demographic and clinical characteristic of the participants: All participants Group I Group II Test value P-value Sig. No- 60 No. = 30 No. = 30 Sex Females 9 (15.0%) 4 (13.3%) 5 (16.7%) 0.131* 0.718 NS Males 51 (85.0%) 26 (86.7%) 25 (83.3%) Age Mean ± SD 12.7 ± 2.48 12.57 ± 3.00 12.83 ± 1.86 -0.414• 0.681 NS Range 6–16 6–16 10–16 Height (cm) Mean ± SD 146.98 ± 12.37 145.57 ± 15.36 148.40 ± 8.46 -0.885• 0.380 NS Range 110–162 110–162 135–160 Weight (kg) Mean ± SD 45.87 ± 9.79 44.40 ± 11.50 47.33 ± 7.62 -1.164• 0.249 NS Range 21–60 21–60 38–59 BMI Mean ± SD 20.95 ± 1.5 20.58 ± 1.75 21.32 ± 1.12 -1.942• 0.057 NS Range 17.44–24.03 17.44–24.03 19.9–23.05 CARS Mean ± SD 35.73 ± 6.26 34.83 ± 6.02 36.63 ± 6.46 -1.116• 0.269 NS Range 30–51 30–51 30–50 Vineland Mean ± SD 111.9 ± 20.94 108.27 ± 17.19 115.53 ± 23.86 -1.353• 0.181 NS Range 79–148 79–148 80–148 P-value > 0.05: Non-significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant,*: Chi-square test; •: Independent t-test Correlation between each of BMI, CARS and Vineland scores with the other studied parameters in group I and group II before intervention : In group I: There was a negative correlation between MABC2 SD and BMI indicating that with increased body weight there is more motor deficit. There was a positive correlation between the QNST and CARS scores indicating that the more the severe the autistic symptoms the more the deficit in QNST There was a positive correlation between the QNST and Vineland scores indicating that lower adaptive function is associated with more neurological deficit in QNST In group II: There was a negative correlation between MABC2 SD and BMI indicating that with increased body weight there is more motor deficit. There was a negative correlation between the MABC2 and CARS scores indicating that more severe autistic symptoms is associated with more motor deficit. There was a positive correlation between the MABC2 and Vineland scores indicating that higher adaptive function is associated with better motor function. (Table 2 ) Table 2 Correlation between each of BMI, CARS and Vineland scores with the other studied parameters in group I and group II before intervention Group I BMI CARS Vineland r P-value r P-value r P-value MABC-2 balance subscale (pre) Total score -0.311 0.095 -0.170 0.369 0.320 0.084 SD -0.463** 0.010 -0.090 0.637 0.158 0.403 Percentile -0.325 0.080 -0.019 0.919 0.081 0.669 QNST total score pre 0.182 0.335 0.493** 0.006 -0.413* 0.023 Group II MABC-2 balance subscale (pre) Total score -0.715** 0.000 -0.401* 0.028 0.515** 0.004 SD -0.337 0.069 -0.295 0.113 0.379* 0.039 Percentile -0.586** 0.001 -0.293 0.116 0.491** 0.006 QNST total score pre 0.118 0.535 -0.329 0.076 -0.284 0.128 P-value > 0.05: Non-significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant Spearman correlation coefficient Outcome parameters : At baseline and according to the comparable percentiles of the balance subscale of MABC-2, participants in both groups were in the red zone (percentile ≤ 5). There was no significant difference between both groups regarding MABC-2 balance subscale total score, SD and percentile (p = 0.427, 0.132, 0.208 respectively) and QNST (p = 0.603) at baseline (Table 3 ). Both the post-intervention and 2-month follow-up balance subscale of MABC-2 and QNST were significantly higher in group I in comparison to group II (Table 3 ). Both patient groups showed a statistically significant difference in MABC-2 balance subscale and QNST when the baseline was compared to post-intervention and when the baseline was compared to the follow-up parameters (Table 4 ). Similarly, when the two groups were compared regarding the percentage of change from baseline to post-intervention and from baseline to 2 month follow up for the MBC-2 balance subscale and QNST, the percentage of change was significantly higher in group I in comparison to group II (Table 5 ). tDCS´s adverse effects: tDCS was well tolerated, in group I, 4patients (13.33%) reported tingling sensation under the active electrodes which disappeared after few seconds of stimulation; irritability was reported by the mother of 3 children while sleepiness was reported by the mother of one patient (10%, 3.33%) respectively, both disappeared by the fourth day of tDCS sessions. Table 3 Comparison between group I and group II regarding MABC-2 balance subscale and QNST: parameter Group I Group II Test value P-value Sig. No. = 30 No. = 30 MABC-2 balance subscale Pre Total score Mean ± SD 15.07 ± 1.86 14.83 ± 1.78 -0.795≠ 0.427 NS Range 10–17 13–17 SD Mean ± SD 4.53 ± 0.82 4.33 ± 0.71 -1.506≠ 0.132 NS Range 2–5 3–5 Percentile Mean ± SD 3.90 ± 1.62 3.40 ± 1.52 -1.260≠ 0.208 NS Range 0.5–5 2–5 Post Total score Mean ± SD 125.42 ± 38.04 28.12 ± 23.80 -6.492≠ 0.000 HS Range 64.29–171.43 11.76–84.62 SD Mean ± SD 182.17 ± 79.90 37.56 ± 21.47 -6.602≠ 0.000 HS Range 75–300 20–75 Percentile Mean ± SD 1796.53 ± 1159.56 609.33 ± 1233.85 -5.096≠ 0.000 HS Range 640–4800 80–3700 follow-up Total score Mean ± SD 133.25 ± 47.10 25.12 ± 19.79 -6.664≠ 0.000 HS Range 75–228.57 5.88–58.82 SD Mean ± SD 187.67 ± 97.88 30.22 ± 26.11 -6.701≠ 0.000 HS Range 80–375 0–66.67 Percentile Mean ± SD 1982.50 ± 1418.45 160.00 ± 147.62 -6.719≠ 0.000 HS Range 640–4900 0–400 QNST Pre Total score Mean ± SD 29.30 ± 13.53 24.71 ± 9.24 -0.520≠ 0.603 NS Range 8–59 9–45 Post Total score Mean ± SD 7.46 ± 3.59 26.93 ± 10.00 -4.893≠ 0.000 HS Range 1–35 8–37 Follow up Total score Mean ± SD 12.20 ± 9.90 26.93 ± 10.00 -4.893 0.000 HS Range 2–42 9–40 P-value > 0.05: Non-significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant, ≠: Mann-Whitney test Table 4 Comparison of outcome parameter (pre, post and at follows up) among each patient group: Parameter Pre Post Follow-up Test value P-value Sig. MABC-2- balance Group I Total score Mean ± SD 15.07 ± 1.86 34.07 ± 7.36 34.80 ± 6.71 46.974≠ 0.000 HS Range 10–17 19–46 26–46 SD Mean ± SD 4.53 ± 0.82 12.77 ± 4.31 12.73 ± 4.27 49.164≠ 0.000 HS Range 2–5 6–19 8–19 Percentile Mean ± SD 3.90 ± 1.62 67.33 ± 34.08 64.89 ± 31.04 49.164≠ 0.000 HS Range 0.5–5 9–99.9 25–99.9 Group II Total score Mean ± SD 14.83 ± 1.78 18.90 ± 3.39 18.53 ± 3.71 48.857≠ 0.000 HS Range 13–17 15–24 15–27 SD Mean ± SD 4.33 ± 0.71 5.87 ± 0.82 5.53 ± 1.04 42.857≠ 0.000 HS Range 3–5 5–7 5–8 Percentile Mean ± SD 3.40 ± 1.52 17.27 ± 23.70 8.20 ± 6.84 42.857≠ 0.000 HS Range 2–5 5–76 5–25 QNST Group I Total Mean ± SD 29.30 ± 13.53 7.46 ± 3.59 12.20 ± 9.90 -4.789≠ 0.000 HS Range 8–59 1–35 2–42 Group II Total Mean ± SD 29.50 ± 11.83 26.93 ± 10.00 26.93 ± 10.00 -4.169≠ 0.000 HS Range 9–45 8–37 9–40 P-value > 0.05: Non-significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant, ≠: Friedman test Table 5 Comparison between group I and II regarding the percentage of change of the outcome parameters: Percentage of change Group I Group II Test value P-value Sig. MABC-2 balance subscale post Total score Mean ± SD 125.42 ± 38.04 28.12 ± 23.80 -6.492≠ 0.000 HS Range 64.29–171.43 11.76–84.62 SD Mean ± SD 182.17 ± 79.90 37.56 ± 21.47 -6.602≠ 0.000 HS Range 75–300 20–75 Percentile Mean ± SD 1796.53 ± 1159.56 609.33 ± 1233.85 -5.096≠ 0.000 HS Range 640–4800 80–3700 Follow up Total score Mean ± SD 133.25 ± 47.10 25.12 ± 19.79 -6.664≠ 0.000 HS Range 75–228.57 5.88–58.82 SD Mean ± SD 187.67 ± 97.88 30.22 ± 26.11 -6.701≠ 0.000 HS Range 80–375 0–66.67 Percentile Mean ± SD 1982.50 ± 1418.45 160.00 ± 147.62 -6.719≠ 0.000 HS Range 640–4900 0–400 QNST post Total score Mean ± SD Range -78.59 ± 13.85 -40.68 – -96.67 -12.56 ± 3.91 -6.25–17.78 6.664 0.000 HS Follow up Mean ± SD -61.11 ± 14.00 -6.99 ± 4.62 -6.681≠ 0.000 HS Total score Range -80.56 – -28.81 -11.11–0 P-value > 0.05: Non-significant; P-value < 0.05: Significant; P-value < 0.01: Highly significant, ≠: Mann-Whitney test DISCUSSION Autism is classified as a developmental disorder, as defined by theDSM-5, which identifies two primary symptom domains: abnormal communication and social interaction, and restricted, repetitive stereotyped behaviours, interests, or other activities [ 16 ]. Specific motor signs associated with autism were first described in 1943 by Kanner, who noted motor clumsiness in children with the disorder [ 22 ]. For several decades, clinicians and researchers have advocated for increased attention to issues affecting motor skills [ 23 ]. Altered motor coordination is prevalent among individuals with autism, impacting various movements such as abnormal manual dexterity, poor balance, and irregular gait. However, motor coordination is not thoroughly assessed, resulting in under diagnosed and untreated motor coordination deficits [ 24 ], [ 25 ]. The tDCS is a non-invasive brain stimulation technique that has gained prominence in the recent few last years as an adjuvant treatment for many neurological and psychiatric conditions [ 14 ], [ 26 ], [ 27 ], [ 28 ]. In this study, 60 autistic individuals were divided into two groups, with no significant differences between the groups in terms of sex, age, height, weight, or body mass index (BMI). Additionally, their Childhood Autism Rating Scale (CARS) and Vineland scores showed no significant differences, indicating that their symptoms and adaptive behaviours are within the same range. Furthermore, both groups exhibited no significant differences in the results of the Quick Neurological Screening Test (QNST) and the Movement Assessment Battery for Children-2 (MABC-2) regarding coordination and balance abilities. Group 1 was exposed to both tDCS and a neuro-rehabilitation program to improve balance, while Group 2 participated in the neuro-rehabilitation program only. According to the MABC- 2, the total balance subscale scores of 60 autistic individuals indicated that 100% of the sample fell within the "red zone," with scores at or below the 5th percentile. The total score for Group 1, which received tDCS in conjunction with a neuro- rehabilitation program, ranged from 10 to 17 on the balance subscale, with a mean of15.07 ± 1.86. In contrast, Group 2, which received only the neuro- rehabilitation program, exhibited scores ranging from 13 to 17, with a mean of 14.83 ± 1.78. Both groups were positioned within the red zone percentile scale, with Group 1 scoring between 0.5 and 5, and Group 2scoring between 2 and 5, indicating pathological neurological balance and coordination dysfunction. Neurological soft signs have emerged as an obvious and promising method for assessing autism-associated motor impairment. [ 29 ] [ 30 ] Motor problems in Autism Spectrum Disorder (ASD) are common yet often overlooked features of autism. Recognition and management of these issues could be enhanced by incorporating a domain-specific "specifier" into the ASD diagnostic criteria. The inclusion of motor impairment as a diagnostic specifier could facilitate new opportunities for occupational therapy and other motor skill interventions and accommodations. [ 23 ] [ 25 ] [ 31 ] In this study, the correlation between motor function, the severity of ASD symptoms, and adaptive behaviour demonstrated an equivocal relationship of significance, consistent with the findings of other studies. These studies indicate that although the severity of autistic symptoms is related to motor dysfunction, the relationship is not statistically significant [ 22 ], [ 23 ], [ 24 ]. In the current study, Group 1 exhibited a significant correlation between neurological dysfunction, as measured by the QNST, and the severity of autistic symptoms on the CARS (p = 0.006).Furthermore, greater neurological dysfunction on the QNST was significantly correlated with poorer adaptive behaviour in autistic children, as assessed by the Vineland Adaptive Behaviour Scale (p = 0.023). In group1 there was no significant correlation between the severity of symptoms on CARS and the poor adaptive score on Vineland scale, withMABC-2 balance subscale, while in group 2; there was a significant negative correlation. The severity of symptoms in autistic children, as measured by the CARS, and the lower scores on the Vineland Adaptive Behaviour Scales, demonstrated a significant correlation with poorer outcomes on the balance subscale of the MABC-2, with p-values of 0.028 and 0.004, respectively. Conversely, no significant correlation was observed between the severity of symptoms on the CARS or the Vineland and neurological function as assessed by QNST in group 2of autistic children. The findings suggest that assessing motor function in children with autism may require multiple scales to capture the full extent of motor deficits. Utilizing a comprehensive motor function assessment battery could more effectively identify subtle signs of neurological dysfunction. In this study, among the 60 participants, motor coordination difficulties were identified using the Quick Neurological Screening Test (QNST).Specifically, 5.88% of the participants scored above 50, indicating a higher likelihood of pathological motor incoordination. Meanwhile, 52.94% of the sample scored between 26 and 50, which is considered a suspicious range, and 41.18% scored below 25, indicating normal motor coordination. These findings are consistent with other studies that report clinically significant motor problems in individuals with autism, ranging from 50–95% [ 23 ], [ 32 ]. In this study, the range of QNST scores for Group 1 was 8 to 59, with a mean of 29.3 ± 13.53, while Group 2 exhibited a score range of 9 to 45, with a mean of 29.5 ± 11.83. Both groups fall within the suspicious score range, indicating the presence of neurological soft signs (NSS). This result is consistent with other studies that have identified obvious deficits in motor coordination dysfunction and sensory disintegration as markers in the diagnosis of autism. [ 22 ] Despite substantial evidence indicating the presence of motor impairments in individuals with ASD and the clinical significance of these impairments, motor problems are not yet included in the diagnostic criteria [ 32 ] [ 29 ]. In this study, the neurological dysfunction of the sample was classified within the suspicious range (26–50) on the QNST and within the red zone (≤ 5th percentile) on the MABC-2 scale, categorizing them under neurological soft signs. Autistic individuals evidently require comprehensive support to develop the motor skills necessary for successful engagement in daily activities, as well as in their physical, cognitive, and social domains [ 25 ] [ 33 ]. Establishing a motor specifier could facilitate referrals for comprehensive motor assessments by neuropsychiatrists, physical therapists, and occupational therapists. This would also enable autistic children to access motor-related services [ 23 ] [ 24 ] [ 29 ]. Persistent motor difficulties in individuals with autism constitute a substantial impediment to the execution of autistic children ´s daily activities, social and cognitive development. These challenges are often accompanied by impaired imitation, which subsequently leads to a series of deficits in emotional expression, social sharing, joint attention, and pretend play [ 10 ], [ 23 ]. Although individuals with autism may exhibit significant motor difficulties, a relatively small number receive a diagnosis of Developmental Coordination Disorder (DCD) [ 23 ]. Research has demonstrated a considerable overlap in the behavioural motor characteristics seen in autism, which are regarded as NSS, and those associated with DCD [ 22 ], [ 23 ], [ 24 ], [ 29 ]. There is also an overlap between social and communication disabilities, which manifest in the representation of self and others [ 10 ], [ 30 ], [ 31 ],[ 34 ]. Regarding the results of the MABC-2 balance subscale, Group 1,prior to intervention, was positioned in the red zone percentile (0-5th percentile), with scores ranging from 0.5 to 5 and a mean of 3.90 ± 1.62.Similarly, Group 2's pre-intervention results also placed them in the red zone percentile, with scores ranging from 2 to 5 and a mean of 3.40 ± 1.52. There was no significant difference between the two groups (p = 0.20). Following the intervention, Group 1 exhibited a substantial improvement in their balance subscale percentile scores, ranging from 9 to 99.9, with a mean of 67.33 ± 34.08. In contrast, Group 2 demonstrated a range of5 to 76, with a mean of 17.27 ± 23.70. The difference between the groups was statistically significant (p = 0.0001), indicating a highly significant effect in Group 1, which comprised individuals with ASD who were exposed to both transcranial direct current stimulation (tDCS) and rehabilitation. The follow-up results revealed that Group 1 maintained a percentile scale range of 25 to 99.9, with a mean of 64.89 ± 31.04, suggesting that the group exposed to tDCS and rehabilitation remained in the favourable range after two months. Conversely, Group 2's range decreased to 5 to 25, with a mean of 8.20 ± 6.84, indicating deterioration in balance subscale abilities to a less favourable range after two months. The difference remained highly significant in favour of Group1 (p = 0.0001). The results of the MABC-2 balance subscale demonstrated a significantly notable effect of tDCS on balance in children with ASD, with effects persisting longer than those achieved through neurological rehabilitation training alone. Furthermore, when comparing the percentage of change between the two groups post-intervention, the total score percentage in Group 1 was 125.42, whereas the percentage of change in Group 2 was only 28.12.The percentage of change in the MABC-2 balance subscale follow-up for Group 1 was 133.25, whereas for Group 2, it was only 25.12, indicating highly significant difference (p = 0.0001). These results suggest a more substantial and rapid improvement in the balance subscale, as well as significant maintenance of effect in Group 1, utilizing tDCS as a non-invasive brain stimulation method in children with autism. The comparison of Group 1's scores on the QNST pre-intervention ranged from 8 to 59, with a mean of 29.30 ± 13.53, indicating a suspicious level of neurological coordination soft signs deficits. Post-intervention, following 10 sessions of tDCS over two weeks and a neuro-rehabilitation program, scores returned to normal neurological levels, with a range of 1 to 35 and a mean of 7.46 ± 3.59,reflecting a highly significant positive percentage change of approximately 80.65%. During the two-month follow-up period, the scores remained within the normal range (less than 25), specifically between 2 and 42, with a mean of 12.20 ± 9.90, indicating sustained improvement (p = 0.001) with a highly significant difference. Conversely, in Group 2, the pre-intervention scores for the QNST ranged from 9 to 45, with a mean of 29.50 ± 11.83, suggesting a suspicious level of neurological coordination soft signs deficit (26–50). Post-intervention, the scores showed a slight improvement, ranging from 8 to 37, with a mean of 24.71 ± 9.24. After two months, the follow-up scores ranged from 9 to 40, with a mean of 26.93 ± 10.0, demonstrating a highly significant difference (p = 0.0001) in the maintenance of improvement, although the scores remained at a suspicious level of neurological dysfunction (26–50). A comparison of the percentage of change in QNST scores post-intervention and during follow-up between Group 1 and Group 2 revealed that the range of improvement in Group 1 was from − 80.56 to -28.81, with a mean of -61.11 ± 14.00, whereas in Group 2, the range was from − 11.11 to 0, with a mean of -6.99 ± 4.61 (p = 0.0001). These results indicate a very high significance, suggesting that the combined effect of tDCS and rehabilitation was almost ten times more effective than neurological rehabilitation alone, both post-intervention and during follow-up. Consistent with recent controlled trials, promising results have been observed regarding the use of tDCS in ASD [ 26 ], [ 14 ]. Although the current study employed a tDCS intensity of 1 mA, whereas Mahmoodifar et al. utilized an intensity of 1.5 mA, the efficacy of tDCS in the present study demonstrated comparable outcomes. Both studies applied tDCS to the primary motor cortex [ 6 ]. Consistent with the findings of the current study, Mahmoodifar et al. demonstrated that autistic children aged 6 to 14 years who received both actual transcranial direct current stimulation (tDCS) and motor skill training exhibited significantly better balance compared to those who received sham tDCS and motor skill training [ 6 ].Other studies applied anodal tDCS to the left dorsolateral prefrontal cortex. It was observed that anodal tDCS significantly improved the abnormal motor-related functions associated with autism spectrum disorder (ASD), extending beyond socio-behavioural dysfunction and repetitive motor mannerisms. These improvements included enhancements in gait abnormalities, gross and fine motor function impairments, basic motor control deficits, and reduced postural stability. [ 10 ], [ 26 ], [ 35 ] The observed effects of anodal tDCS may be attributed to its ability to reduce gamma-aminobutyric acid (GABA) levels within the primary sensory-motor cortices. These cortices are crucial in the context of motor learning dysfunction and behavioural abnormalities in children with autism [ 23 ], [ 25 ], [ 33 ]. Additionally, it has been suggested that the benefits of tDCS may include the enhancement of glial cell activity, modulation of mirror 2 neurons, or the adjustment of the atypical excitation/inhibition balance in the autistic brain [ 14 ], [ 26 ], [ 27 ]. Studies have also indicated that the application of a weak electric current can alter the membrane potential of neurons, leading to spontaneous firing rates and changes in the neurons' discharge threshold [ 26 ]. It has been observed tDCS enhances motor skill function in children with ASD, thereby improving their social cognition and imitation functions, which positively influences their social interaction and sociability [ 10 ]. As an alternative therapeutic tool for children with ASD, tDCS facilitates more appropriate motor behaviours, such as body gestures and meaningful facial expressions, which are essential for successful social interaction. These behaviours are based on properly coordinated movement and integrated sensory-motor and balance abilities [ 22 ], [ 25 ], [ 29 ], [ 31 ], [ 35 ]. Recent research indicates that tDCS is a promising intervention for mitigating symptoms of ASD, as well as enhancing both motor skills and neuropsychological functions [ 25 ], [ 26 ], [ 36 ]. Positive outcomes from tDCS studies involving children with ASD demonstrate that the neuroplastic effects of tDCS over the motor and prefrontal regions persist for six months post-treatment, correlating with improvements in the severity of autistic symptoms [ 27 ], [ 35 ]. Other previous researches have indicated that tDCS may confer benefits that persist for up to one year, thereby reducing the severity of autistic symptoms in the affected population [ 14 ], [ 27 ]. Furthermore, the application of anodal tDCS in conjunction with conventional rehabilitation has been associated with more rapid improvements in motor, cognitive, and behavioural domains among children with autism spectrum disorder (ASD) [ 14 ], [ 26 ], [ 27 ],[ 28 ]. Conclusion tDCS is a non- invasive new adjuvant therapeutic approach in ASD. The current study revealed that severe autistic symptoms are associated with greater motor deficits. Immediately after applying tDCS sessions alongside neurorebilitation program; balance subscales and neurological deficits improved significantly more than applying neurorebilitation program alone and this effect continued in the follow- up after two months of the intervention. Recommendation These preliminary findings indicate that transcranial direct current stimulation (tDCS) may enhance motor skills training in children with autism spectrum disorder (ASD). However, further research involving larger sample sizes, encompassing participants with varying levels of autism severity, is necessary. Additionally, a comprehensive assessment of motor skills, correlated with cognitive, social, and emotional aspects beyond the motor functions of individuals with ASD, is required. This should be conducted using diverse tDCS stimulation modalities to substantiate the practical application of this non-invasive brain stimulation in children with autism and other neurodevelopmental disorders. Limitation of the study : Despite the special needs care centre being a tertiary facility with an autism rehabilitation unit that handles numerous cases, only 72participants consented to partake in the study. This limited sample size is attributed to the fact that tDCS is not yet a widely recognized therapeutic approach in Egypt. Furthermore, the study was conducted as a single-centre clinical trial. Abbreviations ASD Autism Spectrum Disorder CARS Childhood Autism Rating Scale DCD Developmental Coordination Disorder DSM- 5 Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition MABC-2 Movement Assessment Battery for Children-2 NSS Neurological Soft Signs QNST Quick Neurological Screening Test tDCS transcranial direct current stimulation. Declarations Acknowledgements We would like to acknowledge Marwa Alazizy for applying Vineland and CARS, Asmaa Msfer. Doaa Elsawy for applying the neurorehabilitation program and we acknowledge thanks all participants and their families in the current study for their valuable time. Authors’ contributions Omnia A. Abubakr (OA) contributed to the study concept and design, clinical assessment, designing of rehabilitation program, gathered all data, and writing and editing of the manuscript. Manal M. Mahdi Omar (MO) contributed to the study concepts and design, analysis and interpretation of results, and writing and editing the manuscript Sara Ali (SA) recruited the studied cases, clinical psychiatric assessment and diagnosis. Dina Y. Elalfy (DE) contributed to the study concept and design, gathered some data, and formed the results, analysis and interpretation of results, writing and editing the manuscript. All authors have read and approved the manuscript. Funding We did not receive any funding for this research. Availability of data and materials Not available Ethics approval and consent to participate Approval of the Faculty of Medicine, Ain Shams University Ethical Committee to conduct the study prior to its commencement (FMASU R144/2024). A written informed consent was obtained from the parents after explanation of the aim of the study and its benefits for their children and an oral consent was taken from the child. Clinical Trial Registry The application of this study to Pan African Clinical Trial Registry has been accepted. The study´s unique identification number for the registry is PACTR202507542338595 Consent for publication All authors agreed to publish this manuscript in the journal after reviewing the final version. Competing interests The authors declare that they have no competing interests. Author details Lecturer, Department of Rheumatology, Rehabilitation and Physical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt [email protected] Associate Professor of Psychiatry, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University [email protected] Lecturer, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University. [email protected] Associate Professor of Pediatrics, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University. [email protected] References Kamp-Becker, I., Smidt, J., Ghahreman, M., Heinzel-Gutenbrunner, M., Becker, K., &Remschmidt, H. (2010). Categorical and dimensional structure of autism spectrum disorders: the nosologic validity of Asperger Syndrome. 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Cite Share Download PDF Status: Published Journal Publication published 02 Dec, 2025 Read the published version in Middle East Current Psychiatry → Version 1 posted Editorial decision: Revision requested 09 Sep, 2025 Reviews received at journal 08 Sep, 2025 Reviewers agreed at journal 30 Aug, 2025 Reviews received at journal 27 Aug, 2025 Reviewers agreed at journal 17 Aug, 2025 Reviewers invited by journal 17 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Submission checks completed at journal 13 Aug, 2025 First submitted to journal 07 Aug, 2025 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-7321706","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":502556243,"identity":"76232dce-9aa1-409f-8202-22435cbdd22f","order_by":0,"name":"Omnia A. Abubakr","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Omnia","middleName":"A.","lastName":"Abubakr","suffix":""},{"id":502556245,"identity":"557ead62-dbc1-4208-a225-5a260ce81eaf","order_by":1,"name":"Manal M. Mahdi Omar","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Manal","middleName":"M. Mahdi","lastName":"Omar","suffix":""},{"id":502556247,"identity":"0bfd230e-a7a7-4100-87ca-5dc13fa27143","order_by":2,"name":"Sara Ali","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"","lastName":"Ali","suffix":""},{"id":502556248,"identity":"a45bcbf0-df37-43bc-98d5-97f97207080c","order_by":3,"name":"Dina Y. Elalfy","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA30lEQVRIiWNgGAWjYDCCAyCigEGGvYH5AANjA9FaDBh4eA6wJZCshceAOC18x3sPfvhgYMfDI5HzTeLnDhs5BvbDRzfg0yJ55lyy5AyDZKCW3G2SvWfSjBl40tJu4NNicCPHQJrHgJnHHqhFgrftcGKDBI8Zfi333xj//mNQD3LYM8m/RGm5wWMmzWBwGKSFTZooWyTP5JhZ9hgc5+HheWZsLduWZsxGyC98x88Y3/hRUS3Hw5788ObbNhs5fvbDx/BqQQCBBBYJEM1GnHIQ4D/A/IF41aNgFIyCUTCSAACwu0iOHw26BwAAAABJRU5ErkJggg==","orcid":"","institution":"Ain Shams University","correspondingAuthor":true,"prefix":"","firstName":"Dina","middleName":"Y.","lastName":"Elalfy","suffix":""}],"badges":[],"createdAt":"2025-08-07 20:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7321706/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7321706/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s43045-025-00583-1","type":"published","date":"2025-12-02T15:57:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":89985007,"identity":"412abe62-2126-4ed3-b731-fa5925857668","added_by":"auto","created_at":"2025-08-27 06:39:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":407199,"visible":true,"origin":"","legend":"\u003cp\u003etDCS electrodes placement; anodal electrode over left primary motor area (C3), the cathode over the right supraorbital area (Fp2)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7321706/v1/7fe1f4faeedc77cb0baa56d6.png"},{"id":89980312,"identity":"3958fd14-6772-41c2-9674-b76653517ce0","added_by":"auto","created_at":"2025-08-27 06:23:01","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":19258,"visible":true,"origin":"","legend":"\u003cp\u003eUnnumbered image in the Methodology section.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFlow Diagram\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Uf1.png","url":"https://assets-eu.researchsquare.com/files/rs-7321706/v1/393c3ed65d326bcf9fe33067.png"},{"id":97724049,"identity":"3af49434-2b95-4807-807b-55abac5794e9","added_by":"auto","created_at":"2025-12-08 16:11:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1833115,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7321706/v1/6e0ebadf-db0f-4c48-b23f-75ac0e83d1ff.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Anodal Transcranial Direct Current Stimulation on Balance in Children with Autism Spectrum Disorder","fulltext":[{"header":"BACKGROUND","content":"\u003cp\u003eAutism spectrum disorder (ASD) is a neurodevelopmental delay condition characterized by behavioural and adaptive functional abnormalities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough behavioural abnormalities are the primary indicators of the disorder, still a significant number of children with ASD present with motor abnormalities, and went through rehabilitation and balance-based exercises due to the adverse effects of motor control issues on their daily lives. Approximately 83% of children with ASD experience varying degrees of difficulty with gross and fine motor functions [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Research has also identified deficiencies in their postural stability, and their gait patterns, which impaired their motor coordination, led to presence of dyspraxia, and delay in the acquisition of their motor milestones and basic motor skills [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA persistent concern for individuals with ASD is standing balance, as many have not achieved the same level of balance as typically developing individuals. When comparing autistic children to their typically developing peers, the former demonstrate poor postural or balance control, evidenced by postural sway in both double-leg and single-leg stances. Maintaining proper balance is crucial for performing daily activities such as dressing, bathing, and engaging in recreational pursuits like sports and bicycling. Children with Autism Spectrum Disorder (ASD) may face challenges in participating in these social and recreational activities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], which can negatively affect their social cognition, communication, and overall engagement. Furthermore, these difficulties hinder their ability to explore their environment, thereby impacting both social and motor development. In this population, such challenges may also contribute to social- communication disorders, including social isolation and anxiety [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003e1\u003c/b\u003eAt the neuroanatomical level of individuals with ASD, exhibit abnormalities in the sub- cortical white matters connectivity and the cerebellum, also atypical connections in the frontal- striatal areas, due to impaired connectivity between the primary sensory areas and motor areas, and abnormalities in the frontal- parietal network, as evidenced increase of the volume and surface area of their gray matter. Neuro- functional impairments in this population include inadequate multisensory integration, impaired sensory input processing, and difficulties with self other mapping. These deficits are posited to underlie the variations in motor performance observed among children with ASD, supporting the hypothesis that transcranial direct current stimulation (tDCS) applied to motor cortical areas may enhance motor abilities in this clinical group [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTranscranial direct current stimulation (tDCS) is a safe, accessible brain stimulation method, considered to be non- invasive that employs surface electrodes to administer a low-intensity monophasic electrical current to the scalp. This technique induces long-lasting changes in cortical excitability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe polarity of the current plays a crucial role in cortical regulation: cathodal stimulation exerts an inhibitory effect by hyperpolarizing the neuronal cell membrane, whereas anodal stimulation enhances the cortical excitability by promoting depolarization of the neuronal cell membrane [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCertain aspects of movement, such as strength, movement direction, speed, acceleration, are linked to the primary motor cortex. Numerous studies involving individuals across various life stages have employed anodal tDCS over this brain region to demonstrate that cortical modulation of neural networks can be facilitated. This modulation can enhance and support the learning and consolidation of motor patterns, particularly when stimulation is combined with motor training [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe impact of anodal tDCS over the left dorsolateral prefrontal cortex [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] or the temporoparietal junction have predominantly been investigated in clinical trials involving autistic children. These studies aim to modulate dysfunctional areas directly associated with the disorder's core diagnostic characteristics, namely impaired executive functions and social communication. Previous trials have demonstrated a reduction in the severity of the disorder's symptoms, particularly concerning social and nonverbal communication, a decrease in stereotyped behaviours, and an enhancement in their working memory [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrently, there exists only one clinical trial that investigates the impact of tDCS on the primary motor cortex during motor training, which demonstrated improvements in balance and motor skills in ASD children [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study seeks to examine the effect of anodal tDCS over the primary motor cortex on balance in patients with ASD.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eParticipants:\u003c/h2\u003e\u003cp\u003e This study was conducted from July 2024 to July 2025, involving 60children diagnosed with ASD who were recruited from the outpatient clinic of the Special Needs Care Centre, Faculty of Postgraduate Childhood Studies, Ain Shams University. The participants adhered to the following criteria:\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eInclusion Criteria:\u003c/h3\u003e\n\u003cp\u003eParticipants were aged between 6 and 17 years and were diagnosed with Autism Spectrum Disorder (ASD) in accordance with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Participants exhibited balance disorders, scoring at or below the 15th percentile on balance subscale of the Movement Assessment Battery for Children-2 (MABC-2) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. They demonstrated the ability to comprehend and communicate with motor training instructors and were capable of executing the prescribed motor learning instructions. There was no alteration in medication within the six months preceding the study or during its duration, and participants did not engage in other regular exercise programs.\u003c/p\u003e\n\u003ch3\u003eExclusion Criteria:\u003c/h3\u003e\n\u003cp\u003eIndividuals with a history of epilepsy or seizures, neurological or neuromuscular disorders or syndromes other than Autism\u003c/p\u003e\u003cp\u003eSpectrum Disorder (ASD), those who have undergone orthopaedic or neurological surgery within 12 months prior to the intervention, or have had any neurosurgical procedures, as well as those with orthopaedic deformities requiring surgical intervention, metallic implants all over the body, or hearing devices, and those who might show difficulty in cooperation, and understanding the proposed activities needed in the present study.\u003c/p\u003e\n\u003ch3\u003eRandomization and Blinding:\u003c/h3\u003e\n\u003cp\u003eFollowing the selection of participants based on the established eligibility criteria and the completion of the pre-intervention assessment, randomization was executed by an independent statistician utilizing a\u003cb\u003e8\u003c/b\u003esimple computer-generated randomization method. Participants were randomly allocated in a 1:1 ratio into two groups, each comprising 30 patients: the experimental ASD group and the control (sham) group. This study was conducted in a double-blind manner, ensuring that the investigators, participants, and their families were unaware of the participants' group assignments. The interventions were administered byan independent, trained physiotherapist who was not involved in this study.\u003c/p\u003e\n\u003ch3\u003eSample Size:\u003c/h3\u003e\n\u003cp\u003eUtilizing the PASS 15 program for sample size calculation, an examination of results from a prior study (Mahmoodifar and Sotoodeh, 2020) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] indicated that transcranial direct current stimulation (tDCS) significantly enhances motor skill training in children with autism spectrum disorder. Assuming an effect size difference of 0.7 between the two groups concerning the improvement in balance scores, and accounting for a 5% adjustment for dropout rate, a sample size of at least 30 patients per group is required to achieve 80% power to reject the null hypothesis of zero effect size. This calculation is based on a population effect size of 0.70 and a significance level (alpha) of 0.05, employing a one-sided two-sample equal-variance t-test.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAssessment:\u003c/h2\u003e\u003cp\u003e\u003cb\u003e2\u003c/b\u003e- All participants underwent comprehensive history taking and clinical examination, which included the assessment of ASD severity by applying the Childhood Autism Rating Scale (CARS). This scale comprises 14 domains evaluating autism behaviours, and a 15th domain assessing general impressions of autism. The total score ranges from 15 to 60, where a score of 30-36.5 indicates mild to moderate degree of autism, and a score of 37\u0026ndash;60 signifies severe degree of autism [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, the adaptive behaviour of individuals with ASD was evaluated using the Vineland Adaptive Behaviour Scales, Second Edition (Vineland-II). This standardized assessment tool measures adaptive behaviour in individuals from birth to 90 years of age, assessing daily living skills, including social and practical abilities. It is widely utilized in clinical and educational settings to identify strengths and weaknesses, support diagnoses, and develop intervention plans.\u003c/p\u003e\u003cp\u003eThe total score ranges from 20 to 160, categorized as follows:\u003c/p\u003e\u003cp\u003eWeak adaptive behaviour: 20\u0026ndash;70, weak-average: 71\u0026ndash;85, average: 86\u0026ndash;114, average-high: 115\u0026ndash;129, and high: 130\u0026ndash;160 [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe primary outcome was evaluated using the balance subscale of the Movement Assessment Battery for Children-2 (MABC-2), a validated and reliable instrument for assessing and identifying impairments in individuals with ASD. This tool includes various tests tailored for distinct age groups: from 3\u0026ndash;6 years, from 7\u0026ndash;11 years, and from 12\u0026ndash;17 years. The balance subscale comprises three items for each age category, consisting of two dynamic and one static test a child's raw score can be converted into an age-based standard score and percentile equivalent for each subscale. Percentiles serve as \"Traffic Lights\" to facilitate interpretation when communicating test results to caregivers and educators, with the following zones: (a) the Red zone: represents percentile scores at or below the 5th percentile, (b) the Amber zone: represents percentile scores between the 6th and 15th percentile, and (c) the Green zone: represents percentile scores above the 15th percentile. The balance subscale of the MABC-2 was administered at baseline, immediately following the intervention, and two months post-intervention. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe Quick Neurological Screening Test (QNST) was applied to assess the secondary outcome at three distinct time duration: baseline, immediately following the intervention, and two months post-intervention. The QNST is a concise, standardized instrument designed to evaluate neurological function, requiring approximately10-15 minutes for administration. It examines various dimensions of neurological function, including cranial nerves, motor function, sensory perception, and coordination. The scoring system categorizes results as follows: a normal score ranges from 0 to 25, a suspicious score from 26 to 50, and a pathological score is indicated by scores greater than 50 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e- Evaluation of Adverse Effects of tDCS: Subsequent to each session and during the follow-up period, participants and their families were queried regarding any side effects experienced as a result of the stimulation process.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e- The transcranial direct current stimulation (tDCS) sessions were administered by a trained physiotherapist utilizing a Brain PremierE1 device (Shenzhen Yingcchi Technology Co, China). Round sponge electrodes with a diameter of five centimetres, soaked in saline, were employed to deliver the direct current. Group 1received stimulation of the left primary motor cortex (M1) (C3) via the anodal electrode of the tDCS, in accordance with the International System of Electrode Placement EEG 10\u0026ndash;20 (Fig.\u0026nbsp;1); the cathodal electrode was positioned over the right supraorbital region (Fp2).\u003c/p\u003e\u003cp\u003eThe current parameters were as follows: duration of 20 minutes and an intensity of 1 mill ampere, with a30-second ramp-up and ramp-down. Conversely, Group 2received sham tDCS over the same area for the same duration (20minutes); however, the stimulator was deactivated after 30seconds to ensure participant blinding. Participants in each group attended 10 sessions of the respective intervention (5 sessions per week for 2 weeks). Participants who failed to attend at least 8sessions in total were excluded from the study [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eNeurorehabilitation program\u003c/strong\u003e\u003cp\u003eImmediately following transcranial direct current stimulation (tDCS), all participated children of both groups were engaged in individualized exercises tailored to their performance on the balance subscale of the Movement Assessment Battery forChildren-2 (MABC-2). Each participant underwent 10 sessions, over two weeks with five sessions per week, each lasting 30 minutes. The exercises were designed to enhance both static and dynamic balance and included activities such as balance board exercises, Swiss ball exercises, balancing on one foot, walking on tiptoes, walking on a balance beam heel-to-toe both forward and backward, as well as jumping and hopping on one leg in both straight and zigzag patterns [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eDemographic data and clinical characteristics:\u003c/h2\u003e\u003cp\u003eThis study comprised 60 participants, including 51 males and 9 females, with ages ranging from 6 to 16 years. The mean Body Mass Index (BMI) of the participants was 20.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5. The mean Childhood Autism Rating Scale (CARS) score was 35.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26, while the mean Vineland Adaptive Behaviour Scales score was 111.9\u0026thinsp;\u0026plusmn;\u0026thinsp;20.94. No statistically significant differences were observed in the aforementioned parameters between the two groups under study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003edemographic and clinical characteristic of the participants:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAll participants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTest value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo- 60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo. = 30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo. = 30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (15.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (13.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (16.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.131*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.718\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMales\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51 (85.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26 (86.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e25 (83.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.414\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.681\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u0026ndash;16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u0026ndash;16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u0026ndash;16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHeight (cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e146.98\u0026thinsp;\u0026plusmn;\u0026thinsp;12.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e145.57\u0026thinsp;\u0026plusmn;\u0026thinsp;15.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e148.40\u0026thinsp;\u0026plusmn;\u0026thinsp;8.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.885\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.380\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110\u0026ndash;162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e110\u0026ndash;162\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e135\u0026ndash;160\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWeight (kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.87\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44.40\u0026thinsp;\u0026plusmn;\u0026thinsp;11.50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47.33\u0026thinsp;\u0026plusmn;\u0026thinsp;7.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.164\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.249\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21\u0026ndash;60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.95\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.32\u0026thinsp;\u0026plusmn;\u0026thinsp;1.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.942\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.057\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.44\u0026ndash;24.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17.44\u0026ndash;24.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.9\u0026ndash;23.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCARS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.73\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e34.83\u0026thinsp;\u0026plusmn;\u0026thinsp;6.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36.63\u0026thinsp;\u0026plusmn;\u0026thinsp;6.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.116\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.269\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30\u0026ndash;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u0026ndash;51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eVineland\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e111.9\u0026thinsp;\u0026plusmn;\u0026thinsp;20.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e108.27\u0026thinsp;\u0026plusmn;\u0026thinsp;17.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e115.53\u0026thinsp;\u0026plusmn;\u0026thinsp;23.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.353\u0026bull;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.181\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79\u0026ndash;148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79\u0026ndash;148\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80\u0026ndash;148\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eP-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01: Highly significant,*: Chi-square test; \u0026bull;: Independent t-test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCorrelation between each of BMI, CARS and Vineland scores with the other studied parameters in group I and group II before intervention\u003c/b\u003e:\u003c/p\u003e\u003cp\u003eIn group I: There was a negative correlation between MABC2 SD and BMI indicating that with increased body weight there is more motor deficit. There was a positive correlation between the QNST and CARS scores indicating that the more the severe the autistic symptoms the more the deficit in QNST\u003c/p\u003e\u003cp\u003eThere was a positive correlation between the QNST and Vineland scores indicating that lower adaptive function is associated with more neurological deficit in QNST\u003c/p\u003e\u003cp\u003eIn group II: There was a negative correlation between MABC2 SD and BMI indicating that with increased body weight there is more motor deficit.\u003c/p\u003e\u003cp\u003eThere was a negative correlation between the MABC2 and CARS scores indicating that more severe autistic symptoms is associated with more motor deficit.\u003c/p\u003e\u003cp\u003eThere was a positive correlation between the MABC2 and Vineland scores indicating that higher adaptive function is associated with better motor function. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCorrelation between each of BMI, CARS and Vineland scores with the other studied parameters in group I and group II before intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eCARS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eVineland\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003er\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMABC-2 balance subscale (pre)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTotal score\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.311\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.095\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.170\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.369\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.320\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.084\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e-0.463**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.090\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.637\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.158\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.403\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePercentile\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.325\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.080\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.919\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.081\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.669\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQNST total score pre\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.182\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.335\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e0.493**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e-0.413*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.023\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGroup II\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMABC-2 balance subscale (pre)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eTotal score\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e-0.715**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e-0.401*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.028\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.515**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eSD\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-0.337\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.069\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.295\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.379*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003ePercentile\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e-0.586**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.293\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.116\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e0.491**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eQNST total score pre\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.118\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.535\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-0.329\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-0.284\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.128\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eP-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01: Highly significant Spearman correlation coefficient\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome parameters\u003c/b\u003e:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAt baseline and according to the comparable percentiles of the balance subscale of MABC-2, participants in both groups were in the red zone (percentile\u0026thinsp;\u0026le;\u0026thinsp;5). There was no significant difference between both groups regarding MABC-2 balance subscale total score, SD and percentile (p\u0026thinsp;=\u0026thinsp;0.427, 0.132, 0.208 respectively) and QNST (p\u0026thinsp;=\u0026thinsp;0.603) at baseline (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBoth the post-intervention and 2-month follow-up balance subscale of MABC-2 and QNST were significantly higher in group I in comparison to group II (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBoth patient groups showed a statistically significant difference in MABC-2 balance subscale and QNST when the baseline was compared to post-intervention and when the baseline was compared to the follow-up parameters (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, when the two groups were compared regarding the percentage of change from baseline to post-intervention and from baseline to 2 month follow up for the MBC-2 balance subscale and QNST, the percentage of change was significantly higher in group I in comparison to group II (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003etDCS\u0026acute;s adverse effects: tDCS was well tolerated, in group I, 4patients (13.33%) reported tingling sensation under the active electrodes which disappeared after few seconds of stimulation; irritability was reported by the mother of 3 children while sleepiness was reported by the mother of one patient (10%, 3.33%) respectively, both disappeared by the fourth day of tDCS sessions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between group I and group II regarding MABC-2 balance subscale and QNST:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" morerows=\"1\" nameend=\"c4\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eparameter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTest value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSig.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNo. = 30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo. = 30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"17\" rowspan=\"18\"\u003e\u003cp\u003e\u003cb\u003eMABC-2 balance subscale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.795\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.427\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e13\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.506\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.132\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-1.260\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.208\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e125.42\u0026thinsp;\u0026plusmn;\u0026thinsp;38.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.12\u0026thinsp;\u0026plusmn;\u0026thinsp;23.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.492\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.29\u0026ndash;171.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.76\u0026ndash;84.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e182.17\u0026thinsp;\u0026plusmn;\u0026thinsp;79.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37.56\u0026thinsp;\u0026plusmn;\u0026thinsp;21.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.602\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u0026ndash;300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u0026ndash;75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1796.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1159.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e609.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1233.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-5.096\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e640\u0026ndash;4800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e80\u0026ndash;3700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003efollow-up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e133.25\u0026thinsp;\u0026plusmn;\u0026thinsp;47.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25.12\u0026thinsp;\u0026plusmn;\u0026thinsp;19.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.664\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u0026ndash;228.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.88\u0026ndash;58.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e187.67\u0026thinsp;\u0026plusmn;\u0026thinsp;97.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30.22\u0026thinsp;\u0026plusmn;\u0026thinsp;26.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.701\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80\u0026ndash;375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u0026ndash;66.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1982.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1418.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e160.00\u0026thinsp;\u0026plusmn;\u0026thinsp;147.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.719\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e640\u0026ndash;4900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u0026ndash;400\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eQNST\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.30\u0026thinsp;\u0026plusmn;\u0026thinsp;13.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e24.71\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-0.520\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.603\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-4.893\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u0026ndash;37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFollow up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12.20\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-4.893\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eP-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01: Highly significant, \u0026ne;: Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of outcome parameter (pre, post and at follows up) among each patient group:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eParameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePre\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePost\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFollow-up\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eTest value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSig.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e\u003cp\u003e\u003cb\u003eMABC-2- balance\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34.07\u0026thinsp;\u0026plusmn;\u0026thinsp;7.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e34.80\u0026thinsp;\u0026plusmn;\u0026thinsp;6.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e46.974\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19\u0026ndash;46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e26\u0026ndash;46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e12.77\u0026thinsp;\u0026plusmn;\u0026thinsp;4.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12.73\u0026thinsp;\u0026plusmn;\u0026thinsp;4.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e49.164\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8\u0026ndash;19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e67.33\u0026thinsp;\u0026plusmn;\u0026thinsp;34.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e64.89\u0026thinsp;\u0026plusmn;\u0026thinsp;31.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e49.164\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.5\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u0026ndash;99.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e25\u0026ndash;99.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e18.90\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e18.53\u0026thinsp;\u0026plusmn;\u0026thinsp;3.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e48.857\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13\u0026ndash;17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15\u0026ndash;24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e15\u0026ndash;27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e42.857\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u0026ndash;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17.27\u0026thinsp;\u0026plusmn;\u0026thinsp;23.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e8.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e42.857\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u0026ndash;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u0026ndash;76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u0026ndash;25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eQNST\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.30\u0026thinsp;\u0026plusmn;\u0026thinsp;13.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e12.20\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-4.789\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u0026ndash;59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u0026ndash;42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e29.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e26.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e26.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-4.169\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u0026ndash;37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e9\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003eP-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01: Highly significant, \u0026ne;: Friedman test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison between group I and II regarding the percentage of change of the outcome parameters:\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003ePercentage of change\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGroup I\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eGroup II\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eTest value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eSig.\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"11\" rowspan=\"12\"\u003e\u003cp\u003e\u003cb\u003eMABC-2 balance subscale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003epost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e125.42\u0026thinsp;\u0026plusmn;\u0026thinsp;38.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.12\u0026thinsp;\u0026plusmn;\u0026thinsp;23.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.492\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.29\u0026ndash;171.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11.76\u0026ndash;84.62\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e182.17\u0026thinsp;\u0026plusmn;\u0026thinsp;79.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37.56\u0026thinsp;\u0026plusmn;\u0026thinsp;21.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.602\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u0026ndash;300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20\u0026ndash;75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1796.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1159.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e609.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1233.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-5.096\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e640\u0026ndash;4800\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e80\u0026ndash;3700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003eFollow up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e133.25\u0026thinsp;\u0026plusmn;\u0026thinsp;47.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e25.12\u0026thinsp;\u0026plusmn;\u0026thinsp;19.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.664\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u0026ndash;228.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5.88\u0026ndash;58.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e187.67\u0026thinsp;\u0026plusmn;\u0026thinsp;97.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30.22\u0026thinsp;\u0026plusmn;\u0026thinsp;26.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.701\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80\u0026ndash;375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u0026ndash;66.67\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ePercentile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1982.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1418.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e160.00\u0026thinsp;\u0026plusmn;\u0026thinsp;147.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.719\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e640\u0026ndash;4900\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u0026ndash;400\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eQNST\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epost\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-78.59\u0026thinsp;\u0026plusmn;\u0026thinsp;13.85\u003c/p\u003e\u003cp\u003e-40.68 \u0026ndash;\u003c/p\u003e \u003cp\u003e-96.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-12.56\u0026thinsp;\u0026plusmn;\u0026thinsp;3.91\u003c/p\u003e\u003cp\u003e-6.25\u0026ndash;17.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6.664\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFollow up\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-61.11\u0026thinsp;\u0026plusmn;\u0026thinsp;14.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-6.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e-6.681\u0026ne;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e-80.56 \u0026ndash;\u003c/p\u003e \u003cp\u003e-28.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-11.11\u0026ndash;0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003eP-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05: Non-significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05: Significant; P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.01: Highly significant, \u0026ne;: Mann-Whitney test\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAutism is classified as a developmental disorder, as defined by theDSM-5, which identifies two primary symptom domains: abnormal communication and social interaction, and restricted, repetitive stereotyped behaviours, interests, or other activities [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Specific motor signs associated with autism were first described in 1943 by Kanner, who noted motor clumsiness in children with the disorder [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. For several decades, clinicians and researchers have advocated for increased attention to issues affecting motor skills [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAltered motor coordination is prevalent among individuals with autism, impacting various movements such as abnormal manual dexterity, poor balance, and irregular gait. However, motor coordination is not thoroughly assessed, resulting in under diagnosed and untreated motor coordination deficits [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe tDCS is a non-invasive brain stimulation technique that has gained prominence in the recent few last years as an adjuvant treatment for many neurological and psychiatric conditions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, 60 autistic individuals were divided into two groups, with no significant differences between the groups in terms of sex, age, height, weight, or body mass index (BMI). Additionally, their Childhood Autism Rating Scale (CARS) and Vineland scores showed no significant differences, indicating that their symptoms and adaptive behaviours are within the same range. Furthermore, both groups exhibited no significant differences in the results of the Quick Neurological Screening Test (QNST) and the Movement Assessment Battery for Children-2 (MABC-2) regarding coordination and balance abilities. Group 1 was exposed to both tDCS and a neuro-rehabilitation program to improve balance, while Group 2 participated in the neuro-rehabilitation program only.\u003c/p\u003e\u003cp\u003e According to the MABC- 2, the total balance subscale scores of 60 autistic individuals indicated that 100% of the sample fell within the \"red zone,\" with scores at or below the 5th percentile. The total score for Group 1, which received tDCS in conjunction with a neuro- rehabilitation program, ranged from 10 to 17 on the balance subscale, with a mean of15.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.86. In contrast, Group 2, which received only the neuro- rehabilitation program, exhibited scores ranging from 13 to 17, with a mean of 14.83\u0026thinsp;\u0026plusmn;\u0026thinsp;1.78. Both groups were positioned within the red zone percentile scale, with Group 1 scoring between 0.5 and 5, and Group 2scoring between 2 and 5, indicating pathological neurological balance and coordination dysfunction. Neurological soft signs have emerged as an obvious and promising method for assessing autism-associated motor impairment. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eMotor problems in Autism Spectrum Disorder (ASD) are common yet often overlooked features of autism. Recognition and management of these issues could be enhanced by incorporating a domain-specific \"specifier\" into the ASD diagnostic criteria. The inclusion of motor impairment as a diagnostic specifier could facilitate new opportunities for occupational therapy and other motor skill interventions and accommodations. [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn this study, the correlation between motor function, the severity of ASD symptoms, and adaptive behaviour demonstrated an equivocal relationship of significance, consistent with the findings of other studies.\u003c/p\u003e\u003cp\u003eThese studies indicate that although the severity of autistic symptoms is related to motor dysfunction, the relationship is not statistically significant [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the current study, Group 1 exhibited a significant correlation between neurological dysfunction, as measured by the QNST, and the severity of autistic symptoms on the CARS (p\u0026thinsp;=\u0026thinsp;0.006).Furthermore, greater neurological dysfunction on the QNST was significantly correlated with poorer adaptive behaviour in autistic children, as assessed by the Vineland Adaptive Behaviour Scale (p\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e\u003cp\u003eIn group1 there was no significant correlation between the severity of symptoms on CARS and the poor adaptive score on Vineland scale, withMABC-2 balance subscale, while in group 2; there was a significant negative correlation. The severity of symptoms in autistic children, as measured by the CARS, and the lower scores on the Vineland Adaptive Behaviour Scales, demonstrated a significant correlation with poorer outcomes on the balance subscale of the MABC-2, with p-values of 0.028 and 0.004, respectively. Conversely, no significant correlation was observed between the severity of symptoms on the CARS or the Vineland and neurological function as assessed by QNST in group 2of autistic children. The findings suggest that assessing motor function in children with autism may require multiple scales to capture the full extent of motor deficits. Utilizing a comprehensive motor function assessment battery could more effectively identify subtle signs of neurological dysfunction. In this study, among the 60 participants, motor coordination difficulties were identified using the Quick Neurological Screening Test (QNST).Specifically, 5.88% of the participants scored above 50, indicating a higher likelihood of pathological motor incoordination. Meanwhile, 52.94% of the sample scored between 26 and 50, which is considered a suspicious range, and 41.18% scored below 25, indicating normal motor coordination. These findings are consistent with other studies that report clinically significant motor problems in individuals with autism, ranging from 50\u0026ndash;95% [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, the range of QNST scores for Group 1 was 8 to 59, with a mean of 29.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.53, while Group 2 exhibited a score range of 9 to 45, with a mean of 29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.83. Both groups fall within the suspicious score range, indicating the presence of neurological soft signs (NSS). This result is consistent with other studies that have identified obvious deficits in motor coordination dysfunction and sensory disintegration as markers in the diagnosis of autism. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eDespite substantial evidence indicating the presence of motor impairments in individuals with ASD and the clinical significance of these impairments, motor problems are not yet included in the diagnostic criteria [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, the neurological dysfunction of the sample was classified within the suspicious range (26\u0026ndash;50) on the QNST and within the red zone (\u0026le;\u0026thinsp;5th percentile) on the MABC-2 scale, categorizing them under neurological soft signs. Autistic individuals evidently require comprehensive support to develop the motor skills necessary for successful engagement in daily activities, as well as in their physical, cognitive, and social domains [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEstablishing a motor specifier could facilitate referrals for comprehensive motor assessments by neuropsychiatrists, physical therapists, and occupational therapists. This would also enable autistic children to access motor-related services [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePersistent motor difficulties in individuals with autism constitute a substantial impediment to the execution of autistic children \u0026acute;s daily activities, social and cognitive development. These challenges are often accompanied by impaired imitation, which subsequently leads to a series of deficits in emotional expression, social sharing, joint attention, and pretend play [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough individuals with autism may exhibit significant motor difficulties, a relatively small number receive a diagnosis of Developmental Coordination Disorder (DCD) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eResearch has demonstrated a considerable overlap in the behavioural motor characteristics seen in autism, which are regarded as NSS, and those associated with DCD [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThere is also an overlap between social and communication disabilities, which manifest in the representation of self and others [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e],[\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding the results of the MABC-2 balance subscale, Group 1,prior to intervention, was positioned in the red zone percentile (0-5th percentile), with scores ranging from 0.5 to 5 and a mean of 3.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62.Similarly, Group 2's pre-intervention results also placed them in the red zone percentile, with scores ranging from 2 to 5 and a mean of 3.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.52. There was no significant difference between the two groups (p\u0026thinsp;=\u0026thinsp;0.20).\u003c/p\u003e\u003cp\u003eFollowing the intervention, Group 1 exhibited a substantial improvement in their balance subscale percentile scores, ranging from 9 to 99.9, with a mean of 67.33\u0026thinsp;\u0026plusmn;\u0026thinsp;34.08. In contrast, Group 2 demonstrated a range of5 to 76, with a mean of 17.27\u0026thinsp;\u0026plusmn;\u0026thinsp;23.70. The difference between the groups was statistically significant (p\u0026thinsp;=\u0026thinsp;0.0001), indicating a highly significant effect in Group 1, which comprised individuals with ASD who were exposed to both transcranial direct current stimulation (tDCS) and rehabilitation. The follow-up results revealed that Group 1 maintained a percentile scale range of 25 to 99.9, with a mean of 64.89\u0026thinsp;\u0026plusmn;\u0026thinsp;31.04, suggesting that the group exposed to tDCS and rehabilitation remained in the favourable range after two months. Conversely, Group 2's range decreased to 5 to 25, with a mean of 8.20\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84, indicating deterioration in balance subscale abilities to a less favourable range after two months. The difference remained highly significant in favour of Group1 (p\u0026thinsp;=\u0026thinsp;0.0001).\u003c/p\u003e\u003cp\u003eThe results of the MABC-2 balance subscale demonstrated a significantly notable effect of tDCS on balance in children with ASD, with effects persisting longer than those achieved through neurological rehabilitation training alone. Furthermore, when comparing the percentage of change between the two groups post-intervention, the total score percentage in Group 1 was 125.42, whereas the percentage of change in Group 2 was only 28.12.The percentage of change in the MABC-2 balance subscale follow-up for Group 1 was 133.25, whereas for Group 2, it was only 25.12, indicating highly significant difference (p\u0026thinsp;=\u0026thinsp;0.0001). These results suggest a more substantial and rapid improvement in the balance subscale, as well as significant maintenance of effect in Group 1, utilizing tDCS as a non-invasive brain stimulation method in children with autism. The comparison of Group 1's scores on the QNST pre-intervention ranged from 8 to 59, with a mean of 29.30\u0026thinsp;\u0026plusmn;\u0026thinsp;13.53, indicating a suspicious level of neurological coordination soft signs deficits. Post-intervention, following 10 sessions of tDCS over two weeks and a neuro-rehabilitation program, scores returned to normal neurological levels, with a range of 1 to 35 and a mean of 7.46\u0026thinsp;\u0026plusmn;\u0026thinsp;3.59,reflecting a highly significant positive percentage change of approximately 80.65%.\u003c/p\u003e\u003cp\u003eDuring the two-month follow-up period, the scores remained within the normal range (less than 25), specifically between 2 and 42, with a mean of 12.20\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90, indicating sustained improvement (p\u0026thinsp;=\u0026thinsp;0.001) with a highly significant difference. Conversely, in Group 2, the pre-intervention scores for the QNST ranged from 9 to 45, with a mean of 29.50\u0026thinsp;\u0026plusmn;\u0026thinsp;11.83, suggesting a suspicious level of neurological coordination soft signs deficit (26\u0026ndash;50).\u003c/p\u003e\u003cp\u003ePost-intervention, the scores showed a slight improvement, ranging from 8 to 37, with a mean of 24.71\u0026thinsp;\u0026plusmn;\u0026thinsp;9.24. After two months, the follow-up scores ranged from 9 to 40, with a mean of 26.93\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0, demonstrating a highly significant difference (p\u0026thinsp;=\u0026thinsp;0.0001) in the maintenance of improvement, although the scores remained at a suspicious level of neurological dysfunction (26\u0026ndash;50). A comparison of the percentage of change in QNST scores post-intervention and during follow-up between Group 1 and Group 2 revealed that the range of improvement in Group 1 was from \u0026minus;\u0026thinsp;80.56 to -28.81, with a mean of -61.11\u0026thinsp;\u0026plusmn;\u0026thinsp;14.00, whereas in Group 2, the range was from \u0026minus;\u0026thinsp;11.11 to 0, with a mean of -6.99\u0026thinsp;\u0026plusmn;\u0026thinsp;4.61 (p\u0026thinsp;=\u0026thinsp;0.0001). These results indicate a very high significance, suggesting that the combined effect of tDCS and rehabilitation was almost ten times more effective than neurological rehabilitation alone, both post-intervention and during follow-up.\u003c/p\u003e\u003cp\u003eConsistent with recent controlled trials, promising results have been observed regarding the use of tDCS in ASD [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although the current study employed a tDCS intensity of 1 mA, whereas Mahmoodifar et al. utilized an intensity of 1.5 mA, the efficacy of tDCS in the present study demonstrated comparable outcomes. Both studies applied tDCS to the primary motor cortex [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eConsistent with the findings of the current study, Mahmoodifar et al.\u003c/p\u003e\u003cp\u003edemonstrated that autistic children aged 6 to 14 years who received both actual transcranial direct current stimulation (tDCS) and motor skill training exhibited significantly better balance compared to those who received sham tDCS and motor skill training [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].Other studies applied anodal tDCS to the left dorsolateral prefrontal cortex. It was observed that anodal tDCS significantly improved the abnormal motor-related functions associated with autism spectrum disorder (ASD), extending beyond socio-behavioural dysfunction and repetitive motor mannerisms. These improvements included enhancements in gait abnormalities, gross and fine motor function impairments, basic motor control deficits, and reduced postural stability. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe observed effects of anodal tDCS may be attributed to its ability to reduce gamma-aminobutyric acid (GABA) levels within the primary sensory-motor cortices. These cortices are crucial in the context of motor learning dysfunction and behavioural abnormalities in children with autism [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdditionally, it has been suggested that the benefits of tDCS may include the enhancement of glial cell activity, modulation of mirror\u003cb\u003e2\u003c/b\u003eneurons, or the adjustment of the atypical excitation/inhibition balance in the autistic brain [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eStudies have also indicated that the application of a weak electric current can alter the membrane potential of neurons, leading to spontaneous firing rates and changes in the neurons' discharge threshold [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIt has been observed tDCS enhances motor skill function in children with ASD, thereby improving their social cognition and imitation functions, which positively influences their social interaction and sociability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. As an alternative therapeutic tool for children with ASD, tDCS facilitates more appropriate motor behaviours, such as body gestures and meaningful facial expressions, which are essential for successful social interaction. These behaviours are based on properly coordinated movement and integrated sensory-motor and balance abilities [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRecent research indicates that tDCS is a promising intervention for mitigating symptoms of ASD, as well as enhancing both motor skills and neuropsychological functions [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Positive outcomes from tDCS studies involving children with ASD demonstrate that the neuroplastic effects of tDCS over the motor and prefrontal regions persist for six months post-treatment, correlating with improvements in the severity of autistic symptoms [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOther previous researches have indicated that tDCS may confer benefits that persist for up to one year, thereby reducing the severity of autistic symptoms in the affected population [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Furthermore, the application of anodal tDCS in conjunction with conventional rehabilitation has been associated with more rapid improvements in motor, cognitive, and behavioural domains among children with autism spectrum disorder (ASD) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e],[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003etDCS is a non- invasive new adjuvant therapeutic approach in ASD. The current study revealed that severe autistic symptoms are associated with greater motor deficits. Immediately after applying tDCS sessions alongside neurorebilitation program; balance subscales and neurological deficits improved significantly more than applying neurorebilitation program alone and this effect continued in the follow- up after two months of the intervention.\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eRecommendation\u003c/h2\u003e\u003cp\u003eThese preliminary findings indicate that transcranial direct current stimulation (tDCS) may enhance motor skills training in children with autism spectrum disorder (ASD). However, further research involving larger sample sizes, encompassing participants with varying levels of autism severity, is necessary. Additionally, a comprehensive assessment of motor skills, correlated with cognitive, social, and emotional aspects beyond the motor functions of individuals with ASD, is required. This should be conducted using diverse tDCS stimulation modalities to substantiate the practical application of this non-invasive brain stimulation in children with autism and other neurodevelopmental disorders.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e\u003cb\u003eLimitation of the study\u003c/b\u003e:\u003c/h2\u003e\u003cp\u003eDespite the special needs care centre being a tertiary facility with an autism rehabilitation unit that handles numerous cases, only 72participants consented to partake in the study. This limited sample size is attributed to the fact that tDCS is not yet a widely recognized therapeutic approach in Egypt. Furthermore, the study was conducted as a single-centre clinical trial.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eASD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAutism Spectrum Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCARS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eChildhood Autism Rating Scale\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDCD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDevelopmental Coordination Disorder\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDSM- 5\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eDiagnostic and Statistical Manual of Mental Disorders- Fifth Edition\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMABC-2\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMovement Assessment Battery for Children-2\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNSS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNeurological Soft Signs\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eQNST\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eQuick Neurological Screening Test\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003etDCS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003etranscranial direct current stimulation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge Marwa Alazizy for applying Vineland and CARS, Asmaa Msfer. Doaa Elsawy for applying the neurorehabilitation program and we acknowledge thanks all participants and their families in the current study for their valuable time.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOmnia A. Abubakr\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(OA)\u003c/strong\u003e contributed to the study concept and design, clinical assessment, designing of rehabilitation program, gathered all data, and writing and editing of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eManal M. Mahdi Omar\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(MO)\u003c/strong\u003e contributed to the study concepts and design, analysis and interpretation of results, and writing and editing the manuscript\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSara Ali\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(SA)\u003c/strong\u003e recruited the studied cases, clinical psychiatric assessment and diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDina Y. Elalfy\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(DE)\u003c/strong\u003e contributed to the study concept and design, gathered some data, and formed the results, analysis and interpretation of results, writing and editing the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe did not receive any funding for this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot available\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval of the Faculty of Medicine, Ain Shams University Ethical Committee to conduct the study prior to its commencement (FMASU R144/2024). A written informed consent was obtained from the parents after explanation of the aim of the study and its benefits for their children and an oral consent was taken from the child.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Registry\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe application of this study to Pan African Clinical Trial Registry has been accepted. The study\u0026acute;s unique identification number for the registry is PACTR202507542338595\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors agreed to publish this manuscript in the journal after reviewing the final version.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eLecturer, Department of Rheumatology, Rehabilitation and Physical Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eAssociate Professor of Psychiatry, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003col start=\"3\"\u003e\n \u003cli\u003eLecturer, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University. [email protected]\u003c/li\u003e\n \u003cli\u003eAssociate Professor of Pediatrics, Department of Medical Studies for Children, Faculty of Postgraduate Childhood Studies, Ain Shams University.\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKamp-Becker, I., Smidt, J., Ghahreman, M., Heinzel-Gutenbrunner, M., Becker, K., \u0026amp;Remschmidt, H. (2010). Categorical and dimensional structure of autism spectrum disorders: the nosologic validity of Asperger Syndrome. 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TITLE\u0026thinsp;=\u0026thinsp;Transcranial direct current stimulation to facilitate neurofunctional rehabilitation in children with autism spectrum disorder: a protocol for a randomized, sham-controlled, double-blind clinical trial JOURNAL\u0026thinsp;=\u0026thinsp;Frontiers in Neurology VOLUME\u0026thinsp;=\u0026thinsp;Volume 14\u0026ndash;2023 YEAR\u0026thinsp;=\u0026thinsp;2023 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eURL\u0026thinsp;=\u0026thinsp;https://www.frontiersin.org/journals/neurology/articles/\u003c/span\u003e\u003cspan address=\"http://URL\u0026thinsp;=\u0026thinsp;https://www.frontiersin.org/journals/neurology/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fneur.2023.1196585 DOI\u0026thinsp;=\u0026thinsp;10.3389/fneur.2023.1196585\u003c/span\u003e\u003cspan address=\"10.3389/fneur.2023.1196585 DOI\u0026thinsp;=\u0026thinsp;10.3389/fneur.2023.1196585\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e ISSN\u0026thinsp;=\u0026thinsp;1664\u0026ndash;2295\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReis, J., Robertson, E. 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The impact of prefrontal transcranial direct current stimulation (tDCS) on theory of mind, emotion regulation and emotional-behavioral functions in children with autism disorder: A randomized, sham-controlled, and parallel-group study. \u003cem\u003eAutism research: official journal of the International Society for Autism Research\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(10), 1985\u0026ndash;2003. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/aur.2803\u003c/span\u003e\u003cspan address=\"10.1002/aur.2803\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWieting, J., Baumann, M. V., Deest-Gaubatz, S., Bleich, S., Eberlein, C. K., Frieling, H., \u0026amp;Deest, M. (2024). 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A Prospective Open-Label Pilot Study of Transcranial Direct Current Stimulation in High-Functioning Autistic Patients with a Dysexecutive Syndrome. \u003cem\u003eNeuropsychobiology\u003c/em\u003e, \u003cem\u003e78\u003c/em\u003e(4), 189\u0026ndash;199. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1159/000501025\u003c/span\u003e\u003cspan address=\"10.1159/000501025\" 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":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Autism spectrum disorder, transcranial direct current stimulation, balance and motor skills, Movement Assessment Battery for Children-2, Quick Neurological Screening Test","lastPublishedDoi":"10.21203/rs.3.rs-7321706/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7321706/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAutism spectrum disorder (ASD) is a neurodevelopmental delay condition. Although behavioural abnormalities are the primary indicators of the disorder, still a significant number of children with ASD present with motor abnormalities. Research has also identified deficiencies in their postural stability, and their gait patterns, which impaired their motor coordination. Transcranial direct current stimulation (tDCS) is a safe, accessible brain stimulation method, the impact of tDCS on the primary motor cortex during motor training, which demonstrated improvements in balance and motor skills in ASD children had been investigated. The present study seeks to examine the effect of anodal tDCS over the primary motor cortex on balance in patients with ASD\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth groups showed significant difference in MABC-2 balance subscale and QNST when baseline was compared to post-intervention and to the follow-up parameters. Both the post-intervention and follow-up balance subscale of MABC-2 and QNST were significantly higher in group I (who received tDCS sessions and neuro- rehabilitation program) compared to group II (who received rehabilitation program only). Similarly, the percentage of change from baseline to post-intervention and to 2- month follow-up of both MBC-2 balance subscale and QNST was significantly higher in group I in comparison to group II.\u003c/p\u003e\n\u003cp\u003eIn group I there was a positive correlation between the Quick Neurological Screening Test (QNST) and both childhood autism rating scale (CARS) scores and Vineland scores. In group II there was a negative correlation between the Movement Assessment Battery for Children-2 (MABC2) and CARS scores and a positive correlation between the MABC2 and Vineland. In both groups there was a negative correlation between MABC2 SD and BMI\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003etDCS is a non- invasive new adjuvant therapeutic approach in ASD. The current study revealed that severe autistic symptoms are associated with greater motor deficits. Immediately after applying tDCS sessions alongside neurorebilitation program; balance subscales and neurological deficits improved significantly more than applying neurorebilitation program alone and this effect continued in the follow- up.\u003c/p\u003e","manuscriptTitle":"Effect of Anodal Transcranial Direct Current Stimulation on Balance in Children with Autism Spectrum Disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:22:56","doi":"10.21203/rs.3.rs-7321706/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-09T15:44:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-08T21:54:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324119226776215116966350526342182407605","date":"2025-08-30T22:45:08+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-27T16:59:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"333187987018379059614311486605041741335","date":"2025-08-17T12:22:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-17T11:18:12+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-13T09:52:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-13T09:52:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Middle East Current Psychiatry","date":"2025-08-07T20:01:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"middle-east-current-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mecp","sideBox":"Learn more about [Middle East Current Psychiatry](http://mecp.springeropen.com)","snPcode":"43045","submissionUrl":"https://submission.nature.com/new-submission/43045/3","title":"Middle East Current Psychiatry","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"aa08f11b-20e7-41cc-ba42-94228f7f3458","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:05:52+00:00","versionOfRecord":{"articleIdentity":"rs-7321706","link":"https://doi.org/10.1186/s43045-025-00583-1","journal":{"identity":"middle-east-current-psychiatry","isVorOnly":false,"title":"Middle East Current Psychiatry"},"publishedOn":"2025-12-02 15:57:11","publishedOnDateReadable":"December 2nd, 2025"},"versionCreatedAt":"2025-08-27 06:22:56","video":"","vorDoi":"10.1186/s43045-025-00583-1","vorDoiUrl":"https://doi.org/10.1186/s43045-025-00583-1","workflowStages":[]},"version":"v1","identity":"rs-7321706","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7321706","identity":"rs-7321706","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}