Dear Editor

When people consider Randomized Controlled Trials (RCTs), they tend to focus on design issues, which is understandable. RCTs are an essential component of the arsenal of research designs and are the only research design whereby the true relationship between cause and effect can be discerned.

Parkinson's Disease (PD) is a neurodegenerative disorder that causes movement and behavioral problems. Pharmacological advancements for preventing disease progression have limited success for many PD patients; therefore, supportive care is necessary. The advancement of the digital world and the revolution of computerized applications pave the way for a better understanding of PD and inventing technological apparatus for helping PD patients to provide them a more normal life. In this review, the most recent technological advancements regarding the rehabilitation, monitoring, and early prognosis of PD are presented. Furthermore, the possible neurological mechanisms responsible for the positive effects of technological-based interventions are discussed.

Introduction: The acoustic analysis is one of the well-known methods for voice evaluation. In recent years, many studies have investigated the cepstral measures compared with the other former acoustic parameters. This review article evaluates the related studies in the cepstral areas to ascertain whether they are efficient in the diagnosis of dysphonia.
Materials and Methods: We reviewed the available research studies between 2009 and 2021 narratively in PubMed, Scopus, Google Scholar, and Science Direct databases. The searched keywords included “cepstral peak prominence”, “smoothed cepstral peak prominence”, “instrumental acoustic analysis”, “acoustic”, and “diagnosis”. The articles that investigated the power of Cepstral Peak Prominence (CPP) and its smoothed version (CPPS) to differentiate dysphonia versus normal voice have been included. However, the interventional studies that consider CPP and CPPS as one of their adjunct variables and studies that investigated the relationship of the cepstral measure with other parameters were not included.
Results: Recent studies support the efficiency of CPP and CPPS to diagnose dysphonia.
Conclusion: It is reasonable for the voice care teams to use CPP and CPPS in the patients’ initial assessment and track the effects of treatment. However, according to the relatively limited number of studies in this area, more studies are required to clarify the efficacy of cepstral measures in different voice pathologies.

Introduction: This study aimed to estimate the prevalence of dysphonia in patients with COVID-19.
Materials and Methods: English and Persian studies that reported dysphonia in patients with COVID-19 were included. Review and case report studies were excluded. We searched Web of Science, PubMed, Google Scholar, and Scopus from January 1, 2020, to July 15, 2021. The prevalence of dysphonia was obtained by combining the results and weighing the sample sizes in the corresponding studies. Heterogeneity was evaluated using the Cochran Q test and I2
Results: Of the 1830 articles identified, 7 studies (n=1410 patients) were included in the meta-analysis. The pooled prevalence of dysphonia was 31% (%95CI: 13%-48%). The prevalence rates of dysphonia in men and women with COVID-19 were 28.2% (%95CI: 14%-46%) and 32.8% (%95CI: 22%-45%), respectively.
Conclusion: Because of the design of the included studies, the reliability of the results is limited. There was notable heterogeneity in the data, not because of publication bias, but rather the small sample sizes or the heterogeneity of the COVID-19 disease. About one-third of patients with COVID-19 may have dysphonia as the only symptom. Therefore, one should even be careful in approaching those who have only dysphonia.

Introduction: This study evaluated the brain activity based on the linear and nonlinear features of surface electroencephalography (EEG) in the Stroop Color and Word Test (SCWT) and the effect of learning in the test response and related EEG features.
Materials and Methods: A total of 21 women and 19 men with physical and mental health participated in this study. Four stages of this SCWT, consistently in the first and second stages and inconsistently in the third and fourth stages, were taken twice by the participants with a 10-min interval. Besides, EEG recording was simultaneously taken for 1 minute at each stage.
Results: The number of correct responses in the inconsistent stages was lower than that in the consistent stages, while the delay of correct responses was more in the consistent stages. EEG features showed that the relative power band of alpha 1 (8-10 Hz) frequency reduced during the test compared to the resting state. In contrast, the gamma 2 (40-50 Hz) frequency band showed a significant increase. There was no significant difference between various stages of the test and between two repetitions in the test indices and EEG features.
Conclusion: Compared to the resting state, the relative power of alpha 1 and gamma 2 frequency bands changed during SCWT without considering the stage of the test.

Introduction: Professional ethics in Rehabilitation Sciences is necessary for achieving therapeutic goals. Considering the importance of professional ethics training for rehabilitation students, we aimed to investigate the effects of a professional ethics workshop on improving the students’ ethical knowledge at Ahvaz Faculty of Rehabilitation Sciences, Ahvaz City, Iran.
Materials and Methods: This quasi-experimental, cross-sectional study was conducted on all third- and fourth-year students in Audiology, Physiotherapy, Occupational therapy, and Speech therapy and the postgraduate students of the faculty. The two-day workshop was held for 16 hours. The students completed an ethical knowledge assessment test designed by the faculty members before and after the workshop.
Results: The data of 206 students (26% male and 74% female), with a mean age of 25.68 years, were analyzed in this study. The Mean±SD scores of the ethical knowledge test before and after the workshop were 4.71±1.84 and 7.02±1.42, respectively. Based on the results, the ethical knowledge of the students increased significantly after the workshop (P<0.001). Improvement of ethical knowledge scores was significantly different between educational levels (P=0.033). Also, the improvement of ethical knowledge score was significantly different among various study fields (P=0.007).
Conclusion: Considering the promotion of students’ ethical knowledge through participation in this workshop, it is suggested that an ethical workshop be held upon the entry of all rehabilitation students into the clinical field.

Introduction: Children with cleft lips and or palates are at risk for speech and language disorders. Early speech and language intervention help them to advance their full speech and language abilities. This study aimed to determine whether language abilities in toddlers with oral clefts would differ from those of normal children.
Materials and Methods: The study recruited 2 groups of children aged 12 to 24 months. The toddlers with cleft lips and or palates as a group of children with orofacial anomalies were born at Shahid Akbar-Abadi Hospital from March 2017 to March 2019 in Tehran City, Iran. The parents of non cleft children and those with oral clefts answered the questions of the verbal and non-verbal communication screening checklist for Persian-speaking children.
Results: The results showed significant differences between the scores of the receptive-expressive language achieved by toddlers with clefts and non-clefts peers aged 12-18 months (P<0.05) and 18-24 months (P<0.05). But the results showed no significant differences between the non cleft toddlers and those with clefts in non-verbal communication (P>0.05).
Conclusion: The toddlers with orofacial anomalies need early speech and language intervention.

Introduction: The unique long-term challenges that families of children with hearing impairment experience put them at greater risk for increasing parental stress levels. This study seeks whether children’s hearing impairment affects their mothers’ emotional and coping styles with stressful situations.
Materials and Methods: The coping inventory for stressful situations and the maternal emotional styles questionnaire were distributed among 108 mothers of hearing-impaired children and an equal number of mothers of normal children.
Results: In the task-oriented, distraction, and social diversion styles, the mean scores of the mothers of healthy children were significantly higher than those of the mothers of hearing-impaired children. Regarding the emotion-oriented style, the mean score of the mothers of hearing-impaired children was significantly higher than that of the mothers of healthy children. With regard to the emotional coaching style, the mean score of the mothers of healthy children was significantly higher than that of the mothers of hearing-impaired children. There was no statistically significant difference between the two groups in the mean score of emotional dismissing.
Conclusion: It seems that mothers of hearing-impaired children use less effective coping and emotional styles that have adverse consequences for mothers and their children’s development.

Introduction: Children with Specific Learning Disorders (SLD) suffer from some cognitive deficits affecting their school achievement. This study investigated the effect of the combined Working Memory Training Program (WMTP) with the Caillou program (the game-like features of computerized cognitive training programs) on memory (as a cognitive function) and academic achievement in children with SLD.
Materials and Methods: In this pilot randomized controlled trial study, 30 children with SLD, aged 8-11 years, participated. They were randomly allocated to the intervention and control groups. The intervention group received 20 training sessions in 10 weeks, each lasting 30-45 minutes. The control group only participated in the assessment sessions. The primary outcome was verbal working memory skills assessed by the digit span and letter-number sequencing subtests of the Wechsler Intelligence Scale for Children, the fourth edition (WISC-IV). Also, the grades of science, literature, and mathematics were collected as the secondary outcomes. Children were assessed 3 times: baseline (pre-test), after the intervention (post-test), and 2 months after the intervention (follow-up).
Results: Working memory (digit span and letter-number sequencing scores) and mathematics grades were significantly improved in the intervention group, as compared to the control group at the post-test session (P<0.05) and remained in the follow-up session.
Conclusion: Although this combined program effectively improves working memory and mathematic grades, further research is suggested for more academic achievement.

Introduction: Neuromuscular imbalance between right and left sides of Cervical Erector Spinae (CES) muscles can induce pain by applying the asymmetric loads on the spine incorrectly. This study evaluated the symmetry of the right and left cervical flexion-relaxation ratio (FRR) in patients with Non-Specific Chronic Neck Pain (NSCNP) and healthy subjects.We aimed to investigate the symmetry of FRR on the right and left sides of the CES muscles in individuals with and without NSCNP.
Materials and Methods: A total of 25 patients with NSCNP and 25 healthy subjects participated in this study. The surface electromyography activity of CES muscles during four phases of flexion and extension tasks were measured and recorded. Unilateral FRR in the right and left sides of CES muscles was calculated and compared in each group.
Results: Only in NSCNP patients, FRR in the right CES muscle was significantly higher than that in the left one (P<0.05). Also, FRR for bilateral CES muscles was significantly higher in healthy subjects than in NSCNP patients (P<0.001).
Conclusion: The study results indicated a greater FRR asymmetry in CES muscles in NSCNP patients than in healthy subjects. This asymmetry is probably due to the dominance of the limb. Moreover, asymmetric FRR as a kind of neuromuscular imbalance may cause pain due to imposing asymmetric loads on spine structures.

Introduction: Spinal range of motion (ROM) is a potential and modifiable variable that may contribute to the maintenance of upright sagittal alignment. The present study aimed to compare spinal ROM in older females with and without hyperkyphosis and investigate associations between thoracic kyphosis and spinal ROM, back extensor strength (BES), and back extensor endurance (BEE).
Materials and Methods: Sagittal spinal curvature and ROM were measured with the Spinal Mouse. Also, BES and BEE were assessed with a load cell. Variables were compared between older females with and without hyperkyphosis with the independent sample t test. We used the Pearson correlation coefficient to calculate associations between variables. Multiple linear regression was used to find which variable is best associated with kyphosis.
Results: Lumbar and total spinal ROM were lower in the hyperkyphosis compared to the normal group (P<0.05). Thoracic kyphosis was associated with total lumbar ROM (r=-0.30, P=0.03), total spinal ROM (r=-0.35, P=0.01), BES (r=-0.73, P< 0.001), and BEE (r=-0.60, P< 0.001). Multiple linear regression analysis after adjusting for age, weight, and BMI showed that BES (P<0.001) and BEE (P=0.01) but not spinal ROM (P=0.16) were significantly associated with thoracic kyphosis.
Conclusion: Females with hyperkyphosis had lower spinal ROM than those with normal kyphosis. While thoracic kyphosis was significantly associated with total lumbar ROM, total spinal ROM, BES, and BEE, multivariate regression showed that ROM was not a significant contributor to thoracic kyphosis. BES and BEE were significant contributors to thoracic kyphosis and should be targeted in the rehabilitation of hyperkyphosis.

Introduction: Hyponatremia, defined as serum sodium concentration <136 mEq/l, represents one of the most challenging clinical disorder in geriatric rehabilitative settings . It is associated with significant morbidity and mortality. Hyponatremia can be often followed by neurological symptoms caused by cerebral oedema and in severe hyponatremia, patients frequently experience balance disorder and a high risk of falls.
Materials and Method: We report the case of a female patient, followed after an accurate diagnostic work-up for a syndrome of inappropriate antidiuresis (SIADH). Hyponatremia was initially treated with hypertonic saline infusion and then with fluid restriction. In consideration of the poor response to fluid restriction, treatment with tolvaptan was started. The patient experienced walking problems and was evaluated with an EMG computed Gait Analysis before and after that sodium level was normalized.
Results: Gait analysis carried out highlighted neuromuscular instability with alteration of the time parameter and spatial postural deficit. Once corrected the hyposodiemia the patient showed a marked improvement in neuromuscular control with normalization of the temporal and spatial parameter of the step.
Conclusions: The clinical manifestations of the patient with SIADH are related to the severity of hyponatremia and the speed with which the sodium deficit is established. The criteria for the diagnosis of SIADH in a patient with hypotonic hyponatremia remain those established by Bartter and Schwartz in 1967. Our suggestions is so to monitor balance and gait disorders and perform serial measurements of urine and serum osmolarity during rehabilitation process in order to prevent unbalance and falling.