The effect of subthalamic nucleus deep brain stimulation and dopaminergic treatment on dual-task manual dexterity in Parkinson's disease.

BACKGROUND AND PURPOSE: Dual-task manual dexterity is required to perform activities of daily living and is affected by cognitive functions. This study aimed to investigate the effects of two main treatment options, subthalamic nucleus deep brain stimulation (STN-DBS) and dopaminergic treatment (DT), on dual-task manual dexterity and cognitive functions of people with Parkinson's disease (PwPD). METHODS: Twenty-one PwPD were assessed in four different conditions as medication "on-off" and STN-DBS "on-off" in random order. Motor symptoms were measured with the Movement Disorder Society-Unified Parkinson Disease Rating Scale, motor section (MDS-UPDRS-III). Single and dual-task manual dexterity was assessed with the Nine-Hole Peg Test (NHPT) and cognitive functions were assessed with the Stroop Test (ST) and the Trail Making Test (TMT). RESULTS: Both DT and STN-DBS enhanced MDS-UPDRS-III, and the combination of DT and STN-DBS provided further improvement. Only STN-DBS enhanced dominant hand single-task NHPT scores. Non-dominant single-task NHPT scores and dual-task NHPT scores improved with both treatments alone; however, STN-DBS resulted in more improvement than DT. Dual-task interference, ST, and TMT scores improved with both treatments alone; however, combining DT and STN-DBS did not provide more improvement. CONCLUSION: DT, STN-DBS, and combining both treatments have different effects on motor symptoms, single and dual-task manual dexterity, dual-task interference, and cognitive functions. These results indicate that DT and STN-DBS may affect motor and cognitive functions via different mechanisms. Effects of DT and STN-DBS on manual dexterity may depend on the degree of cognitive involvement in manual dexterity tasks.

Impaired trunk control and its relationship with balance, functional mobility, and disease severity in patients with cervical dystonia.

BACKGROUND: Impaired trunk control is common in neurological disorders; however, trunk control has not been examined in patients with cervical dystonia (CD). Therefore, the primary aim was to compare trunk control between patients with CD and healthy people. The secondary aim was to investigate the relationship between trunk control and balance, functional mobility, and disease severity in patients with CD. METHODS: ]This cross-sectional study included 32 patients with CD and 32 healthy people. Trunk control was compared using the trunk impairment scale (TIS) that consists of three subscales: static sitting balance, dynamic sitting balance, and trunk coordination between two groups. Balance was assessed using Berg Balance Scale, four square step test, and one-leg stance test. The Timed Up and Go Test was measured to determine functional mobility. Toronto Western Spasmodic Torticollis Rating Scale was used to evaluate disease severity.]>

Effect of dual-task training on balance in older adults: A systematic review and meta-analysis.

PURPOSE: Our review aims to analyze the effect of dual-task training (DTT) on balance in healthy older adults. METHODS: PubMed, EbscoHost, Web of Science (WOS), Scopus, Cochrane Library, MEDLINE, EBSCO Open Dissertations, ULAKBIM (TR Index) and YOK (Council of Higher Education Thesis Center) databases and the gray literature were searched. The quality of the studies was assessed with the Cochrane Risk of Bias tool and statistical analysis of the data was performed with Comprehensive Meta-Analysis (CMA) software. A funnel plot and Egger's test were used to detect publication bias. Fourteen studies with 691 participants were included. RESULTS: According to the results of our study, DTT was found to have a significant benefit on balance in older adults than the non-intervention group (standardized mean difference (SMD): -0.691: -1.153, -0.229, 95 % confidence interval (CI)). Furthermore, DTT was superior to different intervention groups in improving balance in older adults (SMD: -0.229: -0.441, -0.016, 95 % CI). CONCLUSION: The findings of this review suggest that DTT may be an effective intervention to improve balance in healthy older adults.

The effect of deep brain stimulation on lower extremity dexterity in people with Parkinson's disease.

PURPOSE: To examine the effect of deep brain stimulation (DBS) on lower extremity dexterity in people with Parkinson's disease (PwPD) and to investigate the relationship between this effect and the effect of DBS on measures of different walking characteristics, and other features of Parkinson's disease. MATERIALS AND METHODS: Thirty-six PwPD were included. Assessment was performed twice with DBS "on" and DBS "off" state. RESULTS: The LEDT scores of both extremities, the Unified Parkinson Disease Rating Scale-motor section (UPDRS-III), the 10-Meter Walk Test (TMWT), the Timed Up and Go Test (TUG), the Figure-of-Eight Walk Test (FEWT), and the Three-Meter Backward Walk Test (TMBWT) scores were significantly better in "on" DBS condition than "off" DBS condition. The effect of DBS on lower extremity dexterity is related to age and levodopa equivalent daily dosage (LEDD). The effect of DBS on lower extremity dexterity and the effect of DBS on the bradykinesia, TUG, the FEWT, and the TMBWT were also related. CONCLUSIONS: DBS has a positive effect on lower extremity dexterity. Clinical characteristics such as age and LEDD and the effect of DBS on bradykinesia, walking with turning, curved walking, and backward walking is related with the effect of DBS on lower extremity dexterity.

The age and levodopa equivalent daily dosage values of the patients should be considered when examining lower extremity dexterity in people with Parkinson's disease who have undergone deep brain stimulation (DBS).It may be beneficial to apply exercises to improve lower extremity dexterity for patients whose symptoms of bradykinesia do not progress as expected after DBS.Applying exercises to improve lower extremity dexterity may also be beneficial for patients who have complex walking deficits after DBS.

Effects of multi-task training on motor and cognitive performances in multiple sclerosis patients without clinical disability: a single-blinded randomized controlled trial.

OBJECTIVE: This study aimed to investigate the effects of multi-task training on motor and cognitive performance in People with Multiple Sclerosis (PwMS) without clinical disability compared to single-task training and a control group. METHODS: A total of 42 patients were randomly assigned to three groups labeled as Multi-Task Training Group (MTTG, n:14), Single-Task Training Group (STTG, n:14), and Control Group (CG, n:14). The STTG performed only motor tasks based on the task-oriented training program twice a week for 6 weeks while the MTTG performed the same tasks concurrently with additional motor and cognitive tasks. The CG performed relaxation exercises at home. Postural stability by posturography, walking by Timed Up-and-Go, manual dexterity by Nine-Hole Peg Test, mental tracking by Counting Backward, and verbal fluency by Word List Generation were assessed before and after the intervention under single and dual-task conditions. RESULTS: In the MTTG, both single cognitive and single motor task performances increased, and, moreover, the cognitive Dual-Task Costs (DTCs) decreased although the motor DTCs were not changed significantly. There were significant group-by-time interactions in favor of MTTG only on the mental tracking DTC during walking compared to the STTG. Moreover, the changes in postural and walking DTCs were associated with changes in single-motor task performance. CONCLUSION: This study suggests that multi-task training is effective in reducing cognitive DTC rather than motor DTC under dual-task conditions in PwMS without clinical disability. TRIAL REGISTRATION NUMBER: NCT03512886.

The coin rotation test: a reliable and valid test in people with Parkinson's disease.

PURPOSE: To investigate: (1) the interrater, and test-retest reliability of the coin rotation test (CRT) in people with Parkinson's Disease (PwPD); (2) the minimum detectable change in the CRT; (3) the concurrent and known-groups validity of the CRT; and (4) the cut-off times that best discriminate PwPD from healthy people and functionally dependent PwPD from functionally independent PwPD. METHOD: Forty-eight PwPD and 33 healthy people were included. The CRT was administered with the nine-hole peg test, Movement Disorders Society Sponsored Unified Parkinson's Disease Rating Scale, Hoehn and Yahr Scale, Parkinson's Disease Questionnaire-8, and Schwab and England Scale. RESULTS: The CRT had excellent interrater and test-retest reliability. Minimal detectable changes were 5.96 and 8.23 s for the dominant and non-dominant hand, respectively. The CRT correlated with other outcome measures. Significant differences in the CRT times were found between PwPD and healthy people, and between functionally dependent PwPD and functionally independent PwPD. The cut-off times of 12.66 s on the dominant hand and 15.76 s on the non-dominant best discriminated PwPD from healthy people, while 22.99 s on the dominant hand and 23.48 s on the non-dominant best discriminated functionally dependent PwPD from functionally independent PwPD. CONCLUSIONS: The CRT is a reliable, and clinically available tool for assessing manual dexterity in PwPD.Implications for rehabilitationThe coin rotation test is a reliable, valid, and clinically available tool for assessing manual dexterity in Parkinson's Disease.The minimal detectable changes of the coin rotation test are 5.96 s for dominant hand and 8.23 s for the non-dominant hand, which may useful for clinicians and researchers to detect in any true change in manual dexterity after any intervention.The coin rotation test correlated with Parkinson's Disease-specific measurement tools.The coin rotation test times may detect impaired manual dexterity between people with Parkinson's Disease and healthy people, and between functionally dependent and functionally independent in Parkinson's Disease population.

Effects of backward walking training on balance, gait, and functional mobility in people with multiple sclerosis: A randomized controlled study.

BACKGROUND: Backward walking training (BWT) can have a positive effect on balance, gait, and functional mobility in neurological diseases; however, the effectiveness of BWT has not been examined in multiple sclerosis (MS). Therefore, the study aimed to investigate the effects of BWT on balance, gait, and functional mobility in people with MS (PwMS). METHOD: Nineteen PwMS were randomly allocated to either the experimental group (n=10) and the control group (n=9). The experimental group received BWT in addition to conventional walking training (CWT) while the control group only received CWT. Both groups performed training three times a week for 8 weeks. Participants were assessed with the Berg Balance Scale (BBS), four square step test (FSST), activities-specific balance confidence scale (ABC), timed 25-foot walk test (T25FW), dynamic gait index (DGI), 3-meter backward walk test (3MBWT), Multiple Sclerosis Walking Scale-12 (MSWS-12), and timed up and go test (TUG) before and after training. RESULTS: After training, both groups showed significant improvements on the T25FW, and TUG (p<0.05) while only the experimental group showed significant improvements on the BBS, FSST, ABC, DGI, 3MBWT, and MSWS-12 (p<0.05). The experimental group significantly improved more than the control group in all outcomes (p<0.05) except for the T25FW (p=0.202). CONCLUSION: BWT in addition to CWT is an effective way to improve balance, gait, and functional mobility for PwMS. These results suggest that BWT may be a potentially useful treatment approach when added to CWT in the rehabilitation of MS.

Comparison of dual-task costs during different types of walking in people with Parkinson's disease: a controlled study.

INTRODUCTION: Many of the activities in daily living require different walking skills such as straight walking (SW), walking with turning (WwT), curved walking (CW) or backward walking (BW) in a dual-task condition. However, there is a lack of evidence regarding the dual task cost (DTC) during different types of walking. Therefore, this study was planned to compare the DTC during different types of walking in people with Parkinson's disease (PwPD) and healthy controls. METHODS: Thirty-one PwPD and 31 healthy controls were included. Different types of walking were assessed using the 10-Meter Walk Test for SW, the Timed Up and Go Test for WwT, the Figure-of-Eight Walk Test for CW, and the Three-Meter Backward Walk Test for BW. Walking assessments were performed in a single-task and a dual-task condition. RESULTS: The DTC on SW was the lowest in both groups. The DTC on WwT, BW, and CW were similar in healthy controls, whereas the order of the DTC on remaining walking types from lowest to highest was; WwT, BW, and CW in PwPD. Also, the DTC on WwT, BW, and CW were higher in PwPD than healthy controls. However, the DTC on SW was similar in PwPD and healthy controls. CONCLUSION: The DTC is different during SW, WwT, BW, and CW in PwPD. Therefore, walking type should be considered in studies investigating dual task walking in PwPD. Also, dual task exercises consisting of different types of walking should be included in rehabilitation programs of PwPD.

The psychometric properties of the figure-of-eight walk test in people with Parkinson's disease.

PURPOSE: To investigate: (1) the interrater, and test-retest reliability of the figure-of-eight walk test (F8WT) in people with Parkinson's disease (PwPD); (2) the minimum detectable change in the F8WT times; (3) the concurrent and known-groups validity of the F8WT times; and (4) the cut-off times that best discriminate PwPD from healthy people and fallers from non-fallers with PD. METHODS: This was a cross-sectional study. Forty-three PwPD and 34 healthy people were recruited. The F8WT was performed along with the timed up and go test, 10 m walk test, Berg Balance Scale, Activities-Specific Balance Confidence Scale, Unified Parkinson's disease Rating Scale, and Hoehn and Yahr Scale. RESULTS: The F8WT showed good interrater and test-retest reliability (ICC = 0.964-0.978 and ICC = 0.905-0.920, respectively). The MDC was 2.77 s. The F8WT was correlated with other outcome measures. Significant differences in the F8WT times were found between PwPD and healthy people and between fallers and non-fallers with PD (p < 0.001 and p < 0.001, respectively). The cut-off times of 8.43 s best discriminated PwPD from healthy people, while 11.19 s best discriminated fallers from non-fallers with PD. CONCLUSIONS: The F8WT is a reliable, valid, and easy-to-administer tool in assessing the walking skill of PwPD.Implications for rehabilitationThe figure-of-eight walk test (F8WT) is a reliable, valid, and clinically available tool for assessing walking skill in Parkinson's disease (PD).The minimal detectable change of the F8WT is 2.77 s, which may help to determine any real change in walking skill after any intervention.The F8WT correlated with functional mobility, gait speed, balance, balance confidence, and severity and stage of PD.The F8WT times may detect impaired walking skill between people with PD and healthy people, and between fallers and non-fallers with PD.

The reliability and validity of the 3-m backward walk test in people with Parkinson's disease.

BACKGROUND: People with Parkinson's disease (PwPD) lose the ability in backward walking which is an important part of mobility in daily life. The 3-m backward walk test (3MBWT) evaluates backward walking; however, its reliability and validity have not been examined in PwPD yet. AIMS: To examine (1) the test-retest reliability of the 3MBWT in PwPD; (2) the minimum detectable change in the 3MBWT times; (3) the concurrent and known-groups validity of the 3MBWT; and (4) the optimum cutoff time which best discriminates fallers from non-fallers with Parkinson's disease (PD). METHODS: This cross-sectional study included 36 PwPD and 33 healthy people. The 3MBWT was conducted with the 10-m walk test, timed up and go test, Berg Balance Scale, four square step test, activity-specific balance confidence scale, Movement Disorders Society Sponsored Unified Parkinson's Disease Rating Scale, and Hoehn and Yahr Scale. RESULTS: The 3MBWT demonstrated excellent test-retest reliability (ICC = 0.965). The MDC of 2.13 s was determined. The 3MBWT had moderate to high correlations with the other outcome measures (correlation coefficient ranged from -0.592 to 0.858). On the 3MBWT times, there were significant differences between PwPD and healthy people, and between fallers and non-fallers with PD (p < 0.001 and p < 0.001, respectively). A 3MBWT time of 10.31 s was found to best discriminate fallers from non-fallers with PD. CONCLUSIONS: The 3MBWT is a reliable, valid, and easy to administer outcome measure to assess backward walking performance in PwPD, indicating it to be used in practice and research.

The 3-m backward walk test: reliability and validity in ambulant people with multiple sclerosis.

To investigate: (a) the interrater and test-retest reliability of the 3-m backward walk test (3MBW) in ambulant people with multiple sclerosis (PwMS); (b) minimal detectable change (MDC); (c) concurrent and known-groups validity; and (d) the cutoff time to best discriminate fallers from nonfallers with multiple sclerosis (MS). Forty-nine PwMS and 36 healthy people were included in this cross-sectional study. The 3MBW was administered with the timed up and go test, Berg Balance Scale, four square step test, Falls Efficacy Scale-International, and Expanded Disability Status Scale. The 3MBW was simultaneously performed by two independent raters to examine the interrater reliability while was repeated after 7-10 days to examine the test-retest reliability. The 3MBW showed good interrater reliability [intraclass correlation coefficient (ICC) = 0.987-0.989] and excellent test-retest reliability (ICC = 0.854-0.889). The MDC was found to be 1.69 s. The 3MBW had moderate-to-strong correlations with the other measures. For the 3MBW, PwMS had worse performance than healthy people ( P < 0.001), whereas fallers with MS had worse performance than nonfallers with MS ( P < 0.001). The 3MBW time of 7.86 s was determined to best discriminate fallers from nonfallers with MS. The 3MBW is a reliable, simple, and easy-to-administer tool for assessing backward walking among ambulant PwMS.

The figure-of-eight walk test is a reliable and valid test for assessing walking skill in people with multiple sclerosis.

BACKGROUND: The ability to turn while walking is essential for people's activities of daily living. Difficulties in turning while walking are commonly shown in people with multiple sclerosis (PwMS). The figure-of-eight walk test (F8W) is a clinical test assessing walking skill in a curved pathway; however, its reliability and validity have not been systematically examined for PwMS. PURPOSES: The study is aimed to investigate: (1) the test-retest reliability of the F8W in PwMS; (2) the standard error of measurement and minimum detectable change in the F8W times; (3) the concurrent and known-groups validity of the F8W times; and (4) the cut-off times that best discriminate fallers from non-fallers with MS. METHOD: This cross-sectional study included 41 PwMS and 33 healthy people. The F8W was performed along with the Timed Up and Go Test (TUG), Berg Balance Scale (BBS), Activities-specific Balance Confidence Scale (ABC), and Expanded Disability Status Scale (EDSS). To determine the test-retest reliability, the F8W was conducted twice, 7-10 days apart. The reliability was assessed using the intraclass correlation coefficient (ICC), Bland-Altman plots, standard error of measurement (SEM), and minimal detectable change (MDC). To examine validity, the correlations between the F8W and the TUG, BBS, ABC, and EDSS were assessed using correlation coefficients, and the completion times of the F8W were compared between PwMS and healthy people, and between fallers and non-fallers with MS. The receiver operating characteristic curve was constructed to determine the optimal F8W cut-off time discriminating fallers from non-fallers with MS. RESULTS: The F8W had excellent test-retest reliability with an ICC of 0.916. Bland-Altman plots showed high agreement between sessions. The SEM and MDC were found to be 0.45 and 1.25, respectively. The F8W indicated a moderate to strong correlation with other outcome measures (correlation coefficients ranged from -0.596 to 0.839, p<0.05). On the F8W, PwMS had a longer time than healthy people while fallers had a longer time than non-fallers with MS (p<0.001, and p<0.001, respectively). The cut-off time of 8.52 s best discriminated the fallers from non-fallers with MS. CONCLUSIONS: The F8W is a reliable and clinically available measurement tool for walking skill in PwMS.

The functional reach test in people with multiple sclerosis: a reliability and validity study.

BACKGROUND: Limits of stability (LOS) is a major component of balance dysfunction in people with multiple sclerosis (MS). The functional reach test (FRT) is a clinical LOS assessment; however, its psychometric properties have not been investigated in people with MS yet. Objectives: To investigate: (1) the intrarater, interrater, and test-retest reliability of the FRT in people with MS; (2) the minimum detectable change (MDC) in the FRT distances; (3) the concurrent and discriminant validity of the FRT; and (4) the cutoff distance that best discriminates people with MS from healthy people and fallers from non-fallers with MS. METHODS: Forty-three people with MS and 36 healthy people participated in this study. The FRT was administered along with the instrumented LOS test, Berg Balance Scale, Four Square Step Test, Timed Up and Go Test, and Expanded Disability Status Scale. The FRT was repeated by the same rater after 2 min from the first test session to determine the intrarater reliability and was simultaneously conducted by two independent raters to determine the interrater reliability. The FRT was also repeated after 7-10 days to determine the test-retest reliability. The reliability was quantified using intraclass correlation coefficients (ICC), Bland-Altman plots, and the MDC. The validity was assessed by correlating the FRT distances with the scores of other measures and by comparing the FRT distances between the MS group and healthy people, and between the fallers and non-fallers in the MS group. RESULTS: The FRT demonstrated good to excellent intrarater, interrater, and test-retest reliability with an ICC (3,1) of 0.80-0.88 (p < .001), an ICC (3,2) of 0.94-0.97 (p < .001), an ICC (2,3) of 0.84-0.86 (p < .001), respectively. Bland-Altman analyses showed no systematic bias between the assessments. The MDC was 8.28 centimeters. The FRT was correlated with the other outcome measures (correlation coefficients ranged from 0.31 to 0.79, p < .05 for all). Significant differences in the FRT distances were found between people with MS and healthy people; however, no significant difference was found between the fallers and non-fallers with MS (p < .001 and p = .09, respectively). The cutoff distance of 35.5 centimeters best discriminates healthy people from people with MS while of 28.5 centimeters did not discriminate between the fallers and non-fallers with MS. CONCLUSIONS: The FRT is a reliable, valid, and easy-to-administer tool for assessing LOS in people with MS.

Dual-Task Cost and Related Clinical Features in Patients With Multiple Sclerosis.

This study aimed to investigate the dual-task cost of both motor and cognitive performances in patients with multiple sclerosis (PwMS) and in healthy controls and to determine their relationships with clinical features in PwMS. The participants performed motor tasks (postural stability, walking, and manual dexterity) and cognitive tasks (mental tracking and verbal fluency) under single- and dual-task conditions. The results showed that postural stability under dual-task conditions did not change, whereas walking and manual dexterity deteriorated, regardless of the concurrent cognitive task, in PwMS (median Expanded Disability Status Scale score: 1) and the healthy controls. Verbal fluency decreased during postural stability, whereas it increased during walking, and it was maintained during manual dexterity in both groups. Mental tracking did not change during walking; it declined during manual dexterity in both groups. Mental tracking during postural stability deteriorated in PwMS, while it did not change in the healthy controls. In general, dual-task costs were associated with baseline performances of tasks rather than clinical features. Therefore, baseline performances of both tasks should be increased for improving dual-task performance in PwMS.

Reliability and validity of the timed 360° turn test in people with Parkinson's disease.

PURPOSE: The objectives of this study were to examine (1) the intrarater, interrater, and test-retest reliability of the timed 360° turn test in people with Parkinson's Disease (PwPD); (2) the minimum detectable change in the timed 360° turn test times; (3) the concurrent and discriminant validity of the timed 360° turn test; (4) the cut-off times which best discriminate PwPD from healthy people and fallers from non-fallers with Parkinson's Disease (PD). METHODS: Fifty-four PwPD and 32 healthy people were included. The timed 360° turn test was administered along with Timed Up and Go Test, Berg Balance Scale, Four Square Step Test, Unified Parkinson's Disease Rating Scale, and Hoehn and Yahr Scale. In addition, PwPD were categorized into fallers and non-fallers based on fall history. Reliability analyses were assessed using intraclass correlation coefficients in a subgroup of 38 PwPD. RESULTS: The timed 360° turn test had excellent intrarater, interrater, and test-retest reliability. It was strongly correlated with other outcome measures (p < 0.001). In both sides, significant differences in the timed 360° turn test times were found between PwPD and healthy people and between fallers and non-fallers with PD (p < 0.001 and p < 0.001, respectively). The timed 360° turn test times of 3.76-3.89 s were found to best discriminate PwPD from healthy people, while 5.46-5.74 s were found to best discriminate fallers from non-fallers with PD. The minimum detectable change in the timed 360° turn test times were 1.98 s for dominant side and 1.48 s for non-dominant side in PwPD. CONCLUSIONS: The timed 360° turn test is a reliable, valid, and clinically available tool for assessing turning ability in PwPD.

Effect of task-oriented circuit training on motor and cognitive performance in patients with multiple sclerosis: A single-blinded randomized controlled trial.

BACKGROUND: Exercise training has positive effects on motor and cognitive performance which deteriorates over time in patients with Multiple Sclerosis (MS). The effects of task-oriented circuit training (TOCT) on motor and cognitive performance in patients with MS are not yet clear. OBJECTIVE: The aims of this study are to investigate the effects of TOCT on balance, walking, manual dexterity, cognitive performance, and to determine the extent to which patients are able to transfer changes in their performance to activities of daily living. METHODS: Twenty patients with MS (EDSS: 2-5.5), were randomly assigned to two groups; the task-oriented circuit training group (TOCTG, n:10) and the control group (CG, n:10). The TOCTG received TOCT twice a week for six weeks while the CG performed the relaxation exercises at home. All patients were assessed by using Modified Sensory Organization Test, Berg Balance Scale, Activities-specific Balance Confidence, Timed Up and Go, Functional Gait Assessment, 12-item Multiple Sclerosis Walking Scale, Nine-Hole Peg Test, Brief Repeatable Battery of Neuropsychological Tests, Multiple Sclerosis Neuropsychological Questionnaire. RESULTS: Balance and walking performance were improved after TOCT (p < 0.05), whereas manual dexterity and cognitive performance except for verbal memory did not change significantly (p > 0.05). The CG showed no changes in any measurements (p > 0.05). CONCLUSIONS: TOCT is quite effective to improve balance and walking in patients with MS. However, further studies are needed to determine the effect of TOCT on cognitive performance.