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Integrating multi-session transcranial direct current stimulation with routine physical therapy to improve quadriceps strength and activation in athletes during subacute recovery following ACL reconstruction: A double-blind RCT.

Overview

Authors: Naeemeh Haddadi Esfahani1, Mohammad Mohsen Roostayi2, Volga Hovsepian3, Alireza Akbarzadeh Baghban4, Zahra Sadat Rezaeian5, Shapour Jaberzadeh6
ORCID iDs: Mohammad Mohsen Roostayi
  1. Department of Physiotherapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  2. Physiotherapy Research Center, Department of Physiotherapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  3. Department of Exercise Physiology, Faculty of Sport Sciences, University of Isfahan, Isfahan, Iran
  4. Proteomics Research Center, Department of Biostatistics, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
  5. Musculoskeletal Research Center, Rehabilitation Research Institute and Department of Physical Therapy, Faculty of Rehabilitation Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
  6. Monash Neuromodulation Research Unit (MNRU), Department of Physiotherapy, Monash University, Melbourne, Australia
Institutions: Shahid Beheshti University (Iran); Shahid Beheshti University of Medical Sciences (Iran); University of Isfahan (Iran); Isfahan University of Medical Sciences (Iran); Monash University (Australia)
Journal: PloS one, volume 21, issue 6, article e0345947
Dates: received 29 September 2025; accepted 11 March 2026; published online 11 June 2026
Type: Research article · Language: English
License: CC BY
Identifiers: DOI 10.1371/journal.pone.0345947 · PMID 42275424 · PMCID PMC13257960 · OpenAlex W7164407805
Open access: gold, a free copy (OpenAlex)
Status: data only
Categories: other (modality), human (organism), clinical / translational (subfield)
Methods: Statistics, Preprocessing
MeSH: Anterior Cruciate Ligament Reconstruction*, Athletes*, Muscle Strength*, Physical Therapy Modalities*, Quadriceps Muscle*, Transcranial Direct Current Stimulation*, Adult, Double-Blind Method, Humans, Male, Recovery of Function, Young Adult (* major topic)
Journal subjects: Medicine and Health Sciences, Clinical Medicine, Signs and Symptoms, Pain, Biology and Life Sciences, Anatomy, Musculoskeletal System, Skeleton, Skeletal Joints, Knees, Body Limbs, Legs, Surgical and Invasive Medical Procedures, Functional Electrical Stimulation, Physical Sciences, Physics, Classical Mechanics, Motion, Torque, Sports and Exercise Medicine, Sports Science, Health Care, Physiotherapy, Epidemiology, Medical Risk Factors, Neuroscience, Cognitive Science, Cognitive Psychology, Clinical Psychology, Psychology, Social Sciences
Topic: Transcranial Magnetic Stimulation Studies (Neurology, Neuroscience), according to OpenAlex
Citations: not cited yet (Europe PMC); 58 references in the paper

Abstract

Objective: Anterior cruciate ligament reconstruction (ACLR) is often associated with persistent quadriceps weakness and impaired voluntary activation. Integrating active anodal transcranial direct current stimulation (a-tDCS) with routine physical therapy (RPT) may offer additional neuromodulatory benefits during the subacute phase of rehabilitation in nonprofessional male athletes.

Methods: Twenty male nonprofessional athletes (mean age: 27.50 ± 7.24 years, BMI: 25.83 ± 3.49) were randomly assigned to two groups: active M1 a-tDCS + RPT (n = 10) and sham M1 a-tDCS + RPT (n = 10). Both groups received 10 sessions of a-tDCS during RPT. The active group received 2 mA stimulation for 20 minutes per session, while the sham group received 2 mA for 30 seconds, followed by ramp-down and discontinuation. Quadriceps strength was measured using an isokinetic dynamometer, voluntary activation was assessed using the superimposed burst technique (Central Activation Ration (CAR) method) Baseline measurements were taken after 10 weeks of RPT, prior to the combined intervention phase.

Results: The active a-tDCS group demonstrated a significant improvement in CAR compared to the sham group (mean difference: 6.85%; 95% CI: 1.92–11.77; p = 0.01), while the sham group showed a slight, non-significant decrease (2.54%; p = 0/80). Within-group analysis revealed significant voluntary activation improvements in the active group (p = 0.005), with no significant changes in the sham group (p = 0.59). No significant between-group differences in quadriceps strength were observed (p = 0.4), although both groups showed significant within-group improvements (active: 21.8%, P ≤ 0.001; sham: 14.8%, p = 0.02), likely due to the effects of RPT.

Conclusion: The integration of multi-session a-tDCS with RPT during the subacute phase of ACLR recovery significantly enhanced voluntary activation and knee-specific function, as measured by the International Knee Documentation Committee (IKDC) score. These findings suggested that multiple-channel a-tDCS may facilitate neural activation and functional recovery, with clinically meaningful improvements in IKDC scores observed in the active group.

Trial Registration: Iranian Registry of Clinical Trials (IRCT) Registration Number: IRCT20231113060048N1; Registered on December 28, 2023. URL: https://irct.behdasht.gov.ir/search/result?query=IRCT20231113060048N1

Reproduced under the paper's license (CC BY), from the paper cited above.

Code

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Data

Datasets cited

Data Availability

The dataset DOI is: https://doi.org/10.5281/zenodo.19831812.

Reproduced under the paper's license (CC BY), from the paper cited above.

Versions

The history of this record: each version stored by the harvester or made by a correction of its authors or of the maintainers of its code, and what changed in its facts. The texts of the paper (its abstract, its availability statements) are not part of it; versions that changed only those are not listed.

Version 1, 27 September 2026: the first record

Recorded: type, language, journal, volume, issue, pages, dates, 6 authors, 12 MeSH terms, 55 references.

Cite

This paper

Esfahani, N. H., Roostayi, M. M., Hovsepian, V., Baghban, A. A., Rezaeian, Z. S., & Jaberzadeh, S. (2026). Integrating multi-session transcranial direct current stimulation with routine physical therapy to improve quadriceps strength and activation in athletes during subacute recovery following ACL reconstruction: A double-blind RCT. PloS one, 21(6), e0345947. https://doi.org/10.1371/journal.pone.0345947

BibTeX

@article{esfahani2026integrating,
author = {Esfahani, Naeemeh Haddadi and Roostayi, Mohammad Mohsen and Hovsepian, Volga and Baghban, Alireza Akbarzadeh and Rezaeian, Zahra Sadat and Jaberzadeh, Shapour},
title = {{Integrating multi-session transcranial direct current stimulation with routine physical therapy to improve quadriceps strength and activation in athletes during subacute recovery following ACL reconstruction: A double-blind RCT}},
journal = {PloS one},
year = {2026},
month = jun,
volume = {21},
number = {6},
pages = {e0345947},
publisher = {PLOS},
issn = {1932-6203},
doi = {10.1371/journal.pone.0345947},
url = {https://doi.org/10.1371/journal.pone.0345947},
pmid = {42275424},
pmcid = {PMC13257960}
}

RIS

TY - JOUR
AU - Esfahani, Naeemeh Haddadi
AU - Roostayi, Mohammad Mohsen
AU - Hovsepian, Volga
AU - Baghban, Alireza Akbarzadeh
AU - Rezaeian, Zahra Sadat
AU - Jaberzadeh, Shapour
TI - Integrating multi-session transcranial direct current stimulation with routine physical therapy to improve quadriceps strength and activation in athletes during subacute recovery following ACL reconstruction: A double-blind RCT
T2 - PloS one
J2 - PLoS One
PY - 2026
DA - 2026/06/11
VL - 21
IS - 6
SP - e0345947
SN - 1932-6203
PB - PLOS
DO - 10.1371/journal.pone.0345947
UR - https://doi.org/10.1371/journal.pone.0345947
LA - en
ER -

CSL-JSON

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