**Author details**

Margaret Brocx1 \*, Vic Semeniuk2,3, Tom J. Casadevall4 and Dan Tormey5

1 Environmental and Conservation Sciences, Murdoch University, Western Australia

2 V & C Semeniuk Research Group, Warwick, Western Australia

3 School of Arts and Sciences, Notre Dame University, Fremantle, Western Australia

4 United States Geological Survey, California, USA

5 Catalyst Environmental Solutions, Santa Monica, California, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**Entropy in Heart Rate Dynamics Reflects How HRV-Biofeedback Training Improves Neurovisceral Complexity during Stress-Cognition Interactions**

**Veronique Deschodt-Arsac 1,\*, Estelle Blons 1, Pierre Gilfriche 1,2, Beatrice Spiluttini 3 and Laurent M. Arsac 1**

Received: 6 February 2020; Accepted: 9 March 2020; Published: 11 March 2020

**Abstract:** Despite considerable appeal, the growing appreciation of biosignals complexity reflects that system complexity needs additional support. A dynamically coordinated network of neurovisceral integration has been described that links prefrontal-subcortical inhibitory circuits to vagally-mediated heart rate variability. Chronic stress is known to alter network interactions by impairing amygdala functional connectivity. HRV-biofeedback training can counteract stress defects. We hypothesized the great value of an entropy-based approach of beat-to-beat biosignals to illustrate how HRVB training restores neurovisceral complexity, which should be reflected in signal complexity. In thirteen moderately-stressed participants, we obtained vagal tone markers and psychological indexes (state anxiety, cognitive workload, and Perceived Stress Scale) before and after five-weeks of daily HRVB training, at rest and during stressful cognitive tasking. Refined Composite Multiscale Entropy (RCMSE) was computed over short time scales as a marker of signal complexity. Heightened vagal tone at rest and during stressful tasking illustrates training benefits in the brain-to-heart circuitry. The entropy index reached the highest significance levels in both variance and ROC curves analyses. Restored vagal activity at rest correlated with gain in entropy. We conclude that HRVB training is efficient in restoring healthy neurovisceral complexity and stress defense, which is reflected in HRV signal complexity. The very mechanisms that are involved in system complexity remain to be elucidated, despite abundant literature existing on the role played by amygdala in brain interconnections.

**Keywords:** refined composite multiscale entropy; complexity; central autonomic network; heart rate variability; interconnectivity

#### **1. Introduction**

Although it has become increasingly evident that physiological systems are complex, in the sense that many interdependent components interact at different hierarchical levels and simultaneously operate at different time scales, there can be no direct quantification of complexity in living systems. Rather, an intuitive approach with considerable appeal has been that physiological/biomedical signals that are generated by such systems may carry information on the system complexity, its self-organization, and potential adaptability, so pointing to signal complexity analysis is a reliable way to examine coordinated interactions in neurophysiological networks. Prior knowledge of system organization might allow for anticipating, to some extent, system responses through a dynamical organization as well

as long-term (persistent) adaptations. Accordingly, in controlled conditions, a logical expected system behavior should help in strengthening the link between system complexity if one can demonstrate that signal complexity change concurrently [1]. Ultimately, changes in output signal complexity should reflect interconnectivity at neurophysiological levels [2–4].

It has been known for years that the brain and the heart exhibit permanent top-down and bottom-up interactions that are critical beyond cardiovascular health, for behavioral, cognitive, and emotion regulations [5]. As a link between these two organs, a flexible network of neural structures has been extensively described, which is dynamically organized in response to a variety of internal and external stimuli. This complex circuitry is nicely embodied in the conceptual model of neurovisceral integration [6–8], in which prefrontal-subcortical inhibitory circuits that are critically involved in self-regulation are linked with the heart via the vagus nerve [5–11]. The overall functioning of the many constitutive hierarchical components and their multiple interactions have been studied so far through quantifying high-frequency (HF) modulations in heart rate variability, which is a marker of vagal tone in the system signal output. The so-called vagally-mediated heart rate variability (HF-HRV) has shown a critical non-invasive transdiagnostic marker of psychological states [12] because of the inhibitory action of the prefrontal cortex (PFC), which shapes cognitive-behavioral responses [6,8,13,14].

Studies encompassing psychology, cardiovascular, and neuroimaging domains provide converging evidence of a link between short-range (HF) HRV dynamics and the prefrontal subcortical circuits through an intricate network [15–18]. They collectively point to the critical role of network functional activity for cognitive and emotional self-regulation [5]. Additionally, they designate amygdala as a critical target of stress/anxiety in this circuitry, playing a critical role in system interconnectivity. As a clear illustration of amygdala-dependent interconnectivity, statistical maps of structural covariance in neuroimaging confirmed that amygdala interconnections encompass wide portions of cortical and subcortical regions, which serves as a crucial node in intricate circuits [19]. Amygdala functional connectivity is necessary for a dynamic coordination within the central autonomic network (CAN). Stress-induced disruption in amygdala-driven interconnectivity is clearly reflected in the HRV output signals [18,19].

It follows from above that, reasonably enough, one might expect a causal link between amygdala functional connectivity, a coordinated neurovisceral integration, and complexity in the healthy unconstrained CAN.

Researchers have recently more closely associated mood and cognition to complexity markers in HRV dynamics [20–22]. In agreement with the above assumption, the main observation is that complexity in heartbeat dynamics grows with brain activity, but vanished with stress. Further, multiscale entropy in HRV has been suggested as a reliable marker of coordinated neurovisceral integration during stress-cognition interactions [23], although this is a new recent hypothesis that should be addressed further, by manipulating e.g*.,* stress management. While the response to stress in humans is a healthy adaptive function in situations of acute challenge, a prolonged exposure to stressors might cause persistent dysregulations [12], which affects the CAN, as reflected in a systematically blunted vagal tone [24,25]. Heightened resting vagal HRV helped in demonstrating that the functioning of the whole network can be restored, which has promoted the design of specific interventions that are able to enhance the vagal traffic in people with corrupted cortico-subcortical inhibition [26–28]. Among such interventions, HRV biofeedback (HRVB) training has been shown to be an easy-to-use and reliable method that restores cortical inhibitory control [27], which is beneficial in chronic stressed subjects [29]. The HRVB technique consists in slowing the spontaneous respiratory rate that drives vagal activity toward the same natural frequency of the sympathetic cardiovascular control, to around around 0.1 Hz [26], which establishes resonance among vagal and sympathetic baroreflex control loops. Reaching so-called cardiac coherence provides an increased baroreflex gain, which improves the vagal afferent traffic and bottom-up brain stimulations and, ultimately, restores a degraded psychophysiological state [30,31], or improves defense against episodic stressing events, as shown in students during examinations [32,33]. To date, we have no idea how the signal complexity might change with HRVB training.

The aim of the present study was to provide a novel application of a complexity-based method to evaluate coordination in a neurophysiological network, the CAN, through complexity in its output signal, HRV dynamics.

For that, Refined Composite Multiscale Entropy (RCMSE) in heartbeat time-series was assessed during stress-cognition interactions in self-reported moderately stressed participants, before and after HRVB training to trigger system adaptations. We hypothesized that improved stress defense is associated with greater signal complexity, which could reflect better neurovisceral coordination.

#### **2. Materials and Methods**

#### *2.1. Participants*

The procedures are in agreement with the French law that allows for performing experiments on humans and publishing the obtained results without requiring approbation and ID by an IRB or ethical committee, because the experiments are part of the research training that has been approved by the faculty steering committee, which has full responsibility on the training program. The experimental group ('Heart Rate Variability Biofeedback': HRVB group) consisted of 13 healthy participants (eight males and five females, aged 42.5 ± 15.1 years) performing administrative work at the faculty. They all reported being somewhat stressed (see stress quantification below) and they have difficulty for balancing work, family, and lifestyle. Six unstressed people (four males and two females of similar age) served as the control group (CTRL group).

None of the participants were receiving medical treatment before enrollment. They were required to abstain from food or drink for two hours before the HRVB training procedure, scheduled on early morning and early evening before breakfast and lunch. The participants abstained from caffeine ingestion on the experimental days. After five-weeks of HRVB training, three participants of the HRVB group dropped-out of follow up. They argued for too high constraints being linked to the day-to-day HRVB training. Thus, the final sample undergoing both assessments encompassed 10 subjects (seven males and three females).

#### *2.2. Experimental Protocol*

The experimental protocol consisted of two 10 min sequences that were separated by a few minutes that were dedicated to fill psychological questionnaires. The same sequences were repeated before and after HRV biofeedback training. During each sequence, the subjects stayed quietly seated in front of a computer, breathing at spontaneous rate, while the heartbeat time series were recorded, as described below. The resting conditions corresponded to the first 10 min of watching a calm and soothing documentary. During the second 10 min sequence, the participants performed cognitive tasks in a controlled stressful environment. They had to respond to 31 questions that were displayed on a computer screen, which needed the mental processing of logic, memorization, and calculation in a balanced proportion. Questions were created with the E-Prime software (Psychology Software Tools Inc., Pittsburgh, PA, USA), so that the participants answered by pushing dedicated keys on a keyboard. The added stressors had the form of predetermined response time, visual feedbacks for false responses, and an attentive and evaluative audience (two people standing near the participant and taking notes). Flashing lights crowd noises, car honks, and sirens completed the set of added stressors. The number of questions, the type of logic memorization and mental calculation questions, the negative feedback, and the two people for evaluative audience were different before and after HRVB training to avoid undesired consequences of habituation.

#### *2.3. Heart Rate Variability Biofeedback (HRVB) Training Procedure*

HRVB training was assigned to the experimental group for five weeks. The participants had to control their breathing rate at ~ 6 cycles per min without changing their natural tidal volume, in quiet conditions for 5-min periods twice a day (morning and evening). A connected device that was developed by URGOTECH linked by Bluetooth to a smartphone application, URGOfeel, guided the controlled breathing rate® (URGOTECH, Paris, France). As feedback, heart rate was detected non-invasively by infrared finger photoplethysmograph and processed to detect respiratory sinus arrhythmia (RSA) and the presence of a unique mode (frequency) in HRV, which characterizes cardiac coherence, thereby, suitable conditions for afferent cortical-subcortical stimulation through vagal afferent traffic.

#### *2.4. Psychological Tests*

The participants filled out a series of questionnaires. The Spielberger's State-Trait Anxiety Inventory (STAI [34]) consists of 20 items that measured the subjective feelings of apprehension, tension, nervousness, and worry. The NASA Task Load Index (NASA-TLX [35]) was developed to assess cognitive workload. The participants were asked to evaluate six components on a scale: mental demand, physical demand, temporal demand, performance, effort, and frustration level, as well as the weight of each component, allowing for the calculation of a global cognitive workload index. The Perceived Stress Scale (PSS [36]) wherein 14 items provided information on the frequency of thoughts and feeling regarding the encountered situation.

#### *2.5. Heart Rate Recordings and Analyses*

Cardiac interbeat intervals (R-to-R peaks interval durations) were recorded while using a Polar H10 chest belt that was linked by Bluetooth to a smartphone. Polar chest belts demonstrated great accuracy in assessing RR intervals when compared to ECG recordings [37,38]. The RR (intervals) time series were exported to Matlab (Matlab 2016b, Matworks, Natick, MA, USA) and then analyzed for heart rate variability (HRV) using custom-designed algorithms. Raw data were inspected for artifacts; occasional ectopic beats (irregularity of the heart rhythm involving extra or skipped heartbeats, e.g., premature ventricular contraction and consecutive compensatory pause) were visually identified and manually replaced with interpolated values from adjacent RR intervals. The root mean square of the differences between successive intervals (RMSSD) was computed in the time-domain because RMSSD is an index of very short-term variability that dominantly reflects short-latency vagal modulations [39]. Power Spectral Density (PSD) was obtained by using a Fourier transform after cubic spline resampling of the RR signals (4 Hz). Prior to the computation of discrete Fourier transform (DFT, without windowing), 4 Hz-resampled series were detrended by using a detrending method based on the smoothness priors approach [40]. The smoothing parameter was adjusted at 500 which corresponds to the way a time-varying FIR (finite impulse response) high pass filter with a cut-off frequency around 0.033 Hz operates.

Spectral power was computed in the low frequency band (LF-power; 0.04–0.15 Hz) and the high frequency band (HF-HRV; 0.15–0.4 Hz), and then interpreted as pure sympathetic and dominantly vagal activities, respectively. LF power/HF power was computed as an indicator of sympatho-vagal balance.

Complexity in the RR time series was captured by computing Refined Composite Multiscale Entropy (RCMSE), an improved method for obtaining sample entropy [41,42] at several time scales from coarse-grained time series [43] of moderate length [44]. The rationale of using multiscale entropy analysis lies in the fact that complexity in neurophysiological networks provides them with the essential capacity to operate over many timescales, which makes the rate of information staying high and quite steady over a range of scales, in strong contrast with systems shifting towards disorder (white noise) or strict order (mode locking) [45]. Here, the overall degree of complexity of HRV signals was calculated by integrating the values of sample entropy that were obtained over the shortest scales, which corresponds

to the above described vagal control of heart rate. Refined composite multiscale entropy (RCMSE) improved the accuracy of MSE by reducing the probability of inducing undefined entropy, which is especially useful when analyzing the short time series of cardiovascular dynamics [23], as recently shown [44]. Detailed methods for computing MSE and RCMSE can be found, respectively, in [45] and [44,46]. The RCMSE curve is obtained by plotting sample entropy values for each coarse-grained time series as a function of scales. The cardiac entropy index is the area under the corresponding RCMSE curves (areas calculated using the trapezoidal rule) Figure 1 [44,45]. The entropy indices were computed after pre-processing time series using empirical mode decomposition (EMD) [47], as recommended by Gow et al. [48]. EMD decomposes a signal into a sum of intrinsic mode functions (IMFs) and a residual trend. This residual trend was subtracted to remove the drift, in order to avoid error in entropy assessments [48].

**Figure 1.** Refined composite multiscale entropy (RCMSE) analysis of RR interval time series. Sample entropy values at time scales 1 to 5 during stressful cognitive tasking are reported. The RCMSE curves for the surrogate shuffled time series are also presented. The entropy index represents the trapezoid approximation of the area under each curve: (**left**) Unchanged values in the control group; (**right**) Higher entropy after heart rate variability biofeedback (HRVB) training.

#### *2.6. Statistical Analyses*

The quantitative variables were expressed as mean, standard deviation (SD), and coefficient of variation (CV %).

The normality of each dataset was determined using the d'Agostino–Pearson normality test. One-way analyses of variance followed by paired or unpaired *t-*tests with Bonferroni corrections for multiple comparisons were applied to observe the effects of HRVB training on the psychological and physiological indices. The effect Size with Hedge's *g* was calculated. Values above 0.80 were adopted with high magnitude ('large'), above 0.5 with medium ('med.') and 0.2 with small ('small') magnitude. The Pearson's correlation coefficient was computed for analyzing the relationship between two variables. The Receiver Operating Characteristic (ROC) curve through Sensitivity, Specificity, Area Under Curve defined the efficacy of the HRV indices in time (RMSSD), frequency (HF-HRV, LF-HRV; LF/HF ratio), and non-linear (entropy) domains. The respective *p* values were used between the pre- and post-HRVB training set by Youden Index.

All of the statistical calculations were performed using GraphPad (Prism 8, version 8.2.1, 2019) and XLSTAT (Addinsoft, 2019, XLSTAT statistical and data analysis solution, Long Island, NY, USA).

#### **3. Results**

#### *3.1. Psychological Markers*

Figure 2 illustrates the main adaptations that were induced by HRVB training as regards psychological markers. The adaptations were exclusively observed during the stressful cognitive condition, not at rest Figure 2. State anxiety and Perceived Stress were significantly lower after HRVB training (*p* = 0.0026 and *p* = 0.0165, respectively), whereas the perceived cognitive load (NASA TLX score) remained unchanged (*p* = 0.4258). This observation is not trivial, because it supports the idea that a lower stress/anxiety is not the consequence of less attention being paid to the cognitive task (since the cognitive load is intact), but a pure HRVB training beneficial effect on anxiety and perceived stress when facing our stressful controlled conditions. The absence of changes in the participants of the control group confirmed the pure effect of training. Overall, psychological markers indicate that HRVB training helped participants to prevent a rise in anxiety/stress while facing the stressful cognitive task.

**Figure 2.** Individual changes in psychological markers induced by five-weeks HRV biofeedback training (HRVB) (filled circles) at rest (**left**) and during stressful cognitive tasking (**right**). Open circles indicate mean and standard deviation obtained in control group and illustrate the absence of changes.

#### *3.2. HRV-Based Autonomic Markers*

The main effects of HRVB training on HRV at rest and during stressful cognitive conditions are indicated in Table 1 and in Figure 3 where averaged values in the control group are indicated in order to highlight the specific training effect in the experimental group, not seen in the control group Figure 3.

The RMSSD and HF-HRV values indicate a small effect size of training on vagal activity at rest and a moderate effect during stressful cognitive tasking. The sensitivity analysis demonstrated that the main effects of HRVB training were effective during stressful cognitive tasking Table 2.

We highlighted a link between training benefits at rest and those that were observed during stressful cognitive tasking Figure 4; those participants with the most important gain in resting HF-HRV (resting vagal tone) correlatively demonstrated the most important gain in HF-HRV during stressful cognitive tasking (R2 = 0.789, F = 29.97, *p* = 0.0006, Figure 4).

Taken together, the above adaptations in vagal activity after training indicate that enhanced vagal tone at rest could help in reaching higher vagal control during a stressful task.

Remarkably, autonomic adaptations to training were more consistent and clear-cut when assessed with a complexity marker, RCMSE. First, entropy exhibited a small coefficient of variation (~20%), which contrasts with CV in other markers (mostly >>40%, Table 1). More clearly as well, the entropy index signed benefits of HRVB training, reaching the highest value of effect size during stressful tasking Table 1, as well as higher statistical performances in sensitivity analysis Table 2.

**Table 1.** Mean, standard deviations (SD) and coefficient of variations (CV %) of time-, frequency-, and nonlinear markers extracted from Heart Rate Variability during rest and stressful experimental conditions before and after 5-weeks HRVB training.

RMSSD: Root Mean Square of the Successive Differences; LF-HRV: Low Frequency; HF-HRV: High Frequency; LF/HF: ratio between Low and High Frequencies; Entropy: entropy index calculated from RCMSE analysis.

**Figure 3.** Individual changes in RMSSD, HF-HRV, and Entropy index markers induced by five-weeks HRV biofeedback training (HRVB) (filled circles) at rest (**left**) and during stressful cognitive tasking (**right)**. Open circles indicate mean and standard deviation obtained in control group.

Finally, a link was observed between individual gain in resting vagal power and entropy; with those participants with greater improvement in resting vagal control reaching a higher level of entropy during stressful cognitive tasking (R2 = 0.59, F = 11.42, *p* = 0.009, Figure 5).

**Table 2.** Efficacy of HRV indices in time-, frequency-, and nonlinear domains in the discrimination of HRVB training effects at rest and during stressful cognitive tasking.

RMSSD: Root Mean Square of the Successive Differences; LF-HRV: Low Frequency; HF-HRV: High Frequency; LF/HF: ratio between Low and High Frequencies; Entropy: entropy index calculated from RCMSE analysis; AUC: area under the ROC curve.

**Figure 4.** Correlation analysis between HRVB training gain (calculated as post–pre)/pre \* 100) in high-frequencies (HF)-power during stressful cognitive tasking vs. rest.

**Figure 5.** Correlation analysis between post-training entropy index during stressful cognitive tasking vs. training-induced gain in HF-power (calculated as post–pre)/pre \* 100).

#### **4. Discussions**

The main aim of the present study was to show the value of a complexity-based analysis, refined multiscale entropy (RCMSE), to identify changes in the coordinated interconnectivity of the central autonomic network (CAN). It was hypothesized that a coherent profile in entropy changes during stress-cognition interactions provides a meaningful approach of CAN complexity and neurovisceral adaptability to HRVB training. The main finding in this sense was that entropy in the output signal was heightened despite stress, thanks to HRVB training. This was accompanied with training benefits on vagal activity, which is known to prevent disruption in amygdala functional connectivity [13,18]. We suggest that our results collectively represent a coherent basis to gain improved knowledge on neurovisceral coordination, and by so doing illustrate the link that one can make between system complexity and signal complexity. Here, psychological, vagal, and complexity responses to HRVB training offer a coherent vision of neurovisceral complexity and may open new perspectives for HRV-complexity approaches of heart-brain interactions.

To obtain a realistic interpretation of a link between system complexity and signal complexity in our conditions, a pre-requisite is that autonomic responses and long-term adaptations match with previous observations that consistently report on the link between vagal activity, anxiety, and interconnectivity in the neurovisceral circuitry when the brain has to respond emotionally and cognitively. A low resting vagal HRV and/or an excessive vagal tone withdrawal when one faces an acute challenge has been associated with poor health and poor effectiveness in coping with a variety of stimuli and challenges [49]. These defects in vagal autonomic activity are generally associated with cortico-subcortical dysfunctions [50], which lead to highly susceptibility to amygdala disconnection and a corrupted behavioral and cognitive flexibility. Prolonged exposure to stress is one obvious candidate at the origin of such dysfunctions, being reflected in impaired heart vagal control. In agreement, our moderately stressed participants demonstrated low vagal resting activity and, more critically, a blunted vagal response during stressful tasking Table 1 before HRVB training; remarkably, the vagal activity rose after daily HRVB training thanks to repeated bottom-up vagal stimulations of the brain, especially during stressful cognitive tasking [31,51]. Previous studies have shown that HRV biofeedback training has the capacity to enhance inhibitory control [52] and improve overall self-regulation, autonomic stability, and psychosocial well-being [31], which can be explained by true persistent CAN adaptations. The present work brings about additional support for effective neurovisceral remodeling, being illustrated by measurable benefits of HRVB training that extended beyond resting conditions, in vagally-mediated responses to stressful cognitive tasking, which illustrates profound changes that can be mobilized under different conditions. The correlation between gain in resting and stressful cognitive tasking gain in vagal activity highlights the extended ability to mobilize new resources thanks to the improved CAN dynamic organization Figure 4.

The capacity to maintain high vagal activity at rest as well as during a cognitive task is critical in stress defense [32], and it has been shown to be a pre-requisite for preserving cortico-subcortical inhibition, thereby amygdala functional connectivity [5]. Hence, as a first and critical step for building up a complexity-based concept of neurovisceral coordination, it should be acknowledged that our participants demonstrated an improved vagally-mediated ability to preserve amygdala functional activity during stressful cognitive tasking thanks to HRVB training. This was illustrated here by better vagal (HF-HRV) activity and sympatho-vagal (LF/HF) balance concomitant with a reduction of perceived stress and anxiety after training, which contrasts with poorer status before HRVB training reflected in those markers.

Interestingly enough, we show a correlation between the training-induced gain in vagal activity, which confers better psychophysiological status to a participant [12], and the entropy index that is associated to the stressful cognitive task Figure 5. Hence, better signal entropy while stressful tasking is not without connection with the facilitated vagal control, notwithstanding the fact that entropy demonstrated greater sensitivity than most other autonomic markers to discriminate the training effects Tables 1 and 2. Our interpretative hypothesis, although speculative at this stage, is that the ability of

the entropy index to consistently reflect training induced improvements in neurovisceral integration in the presence of stress might have roots in preserved activity of the main target of anxiety, the amygdala functional connectivity. The reason why entropy, which is a complexity marker, demonstrated that great value might lie in the fact that amygdala activity is critical for subsystems-interconnectivity, as shown by neuroimaging [19]. We speculate here on a possible link between neurovisceral complexity and amygdala functional connectivity, given the multiple connections within and between large portions of cortical (e.g., prefrontal, cingulate, and insula) and subcortical (e.g., striatum, hippocampus, and midbrain) regions and vagal pathways, with the amygdala as a central node in this connected network [19,53]. Giving credit to this overview of the CAN dynamic organization shows the high potential of complexity-based approaches to decipher functional connectivity and coordination in a neurophysiological network.

While we use RCMSE here, a large panel of complexity-based methods for analyzing interbeat time series can be drawn. To evoke a few representative examples, sample entropy has been applied to wavelet-based decomposition in very-low (VLF), low (LF), and high-frequencies (HF) at different ages [54]; multiscale entropy has been applied to diurnal vs. nocturnal series at different ages and health status [45]; the monofractal scaling exponent has been shown to change with ageing, cardiac health, and disease [55,56]; multifractality disruption has been evidenced in heart failure [57]; and, more recently, multifractility-multiscale analysis of both cardiac and vascular dynamics provided a deeper understanding of sexual dymorphism in autonomic control of heart and peripheral vascular districts [58]. In each case, the added value of obtaining complexity metrics was highlighted. The present study is in the same vein by attempting to associate RCMSE with CAN complexity.

Using a multiscale entropy approach for that is not without limitations. Mainly, the significance of sample entropy at given scale strongly depends on the length of the analyzed time series [45,46]. We illustrate the great adequacy of RCMSE, a complexity-based method purposely developed for shorter series [44] to highlight system complexity by showing consistent sample entropy estimates in the present approach from scale 1 to scale 5 Figure 1, from 500–600 data samples series.

In brief, here we suggest that a complexity-based approach of cardiac interbeat time series during stress-cognition interactions is helpful in understanding complexity changes in an intricate central-autonomic neurovisceral circuitry. This statement finds strong support in the combined markers of cognitive load, state anxiety, perceived stress, vagal activity, and entropy, which collectively offered a coherent vision of cooperative mechanisms. Although advanced knowledge on the role of amygdala has recently been provided, an obvious limitation in the present study is the absence of any metrics regarding amygdala functional connectivity or direct evidence of changes in brain networks complexity. Therefore, we conclude that, although HRV biofeedback training appears to be an effective means to preserve a healthy complexity, and that this very property is reflected in HRV entropy, the very mechanisms that link neurovisceral coordination to signal complexity remain to be established.

**Author Contributions:** Conceptualization, V.D.-A., E.B. and B.S.; Methodology, V.D.-A. and E.B.; Software, E.B., L.M.A., P.G. and V.D.-A.; Validation, B.S., E.B., L.M.A. and V.D.-A.; Formal analysis, V.D.-A.; Investigation, E.B. and V.D.-A.; Resources, E.B., L.M.A.,B.S. and V.D.-A.; Data curation, E.B.; Writing—Original draft preparation, L.M.A., and V.D.-A.; Writing—Review and editing, B.S., E.B., L.M.A., P.G. and V.D.-A. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research received no external funding.

**Conflicts of Interest:** The authors declare no conflict of interest.

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© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

## *Article* **Multiscale Entropy of Cardiac and Postural Control Reflects a Flexible Adaptation to a Cognitive Task**

**Estelle Blons 1,\*, Laurent M. Arsac 1, Pierre Gilfriche 1,2 and Veronique Deschodt-Arsac 1**

Received: 16 September 2019; Accepted: 19 October 2019; Published: 21 October 2019

**Abstract:** In humans, physiological systems involved in maintaining stable conditions for health and well-being are complex, encompassing multiple interactions within and between system components. This complexity is mirrored in the temporal structure of the variability of output signals. Entropy has been recognized as a good marker of systems complexity, notably when calculated from heart rate and postural dynamics. A degraded entropy is generally associated with frailty, aging, impairments or diseases. In contrast, high entropy has been associated with the elevated capacity to adjust to an ever-changing environment, but the link is unknown between entropy and the capacity to cope with cognitive tasks in a healthy young to middle-aged population. Here, we addressed classic markers (time and frequency domains) and refined composite multiscale entropy (MSE) markers (after pre-processing) of heart rate and postural sway time series in 34 participants during quiet versus cognitive task conditions. Recordings lasted 10 min for heart rate and 51.2 s for upright standing, providing time series lengths of 500–600 and 2048 samples, respectively. The main finding was that entropy increased during cognitive tasks. This highlights the possible links between our entropy measures and the systems complexity that probably facilitates a control remodeling and a flexible adaptability in our healthy participants. We conclude that entropy is a reliable marker of neurophysiological complexity and adaptability in autonomic and somatic systems.

**Keywords:** heart rate variability; posture; entropy; complexity; cognitive task

#### **1. Introduction**

Physiological control is critical for health and well-being in humans, as it contributes to maintaining homeostasis and the adoption of adequate behaviors. Effective control takes place across intricate networks spanning many neural structures and operating across many time scales. These networks are dynamically organized to respond to internal and external stimuli. The coordinate functioning of the many constitutive components, their multiple interactions within and between systems, and the presence of overlapping control loops have promoted the conceptualization of nonlinear systems, exhibiting complexity [1].

The emergent field of systems physiology exploits the idea that complexity is mirrored in the temporal structure of a system's output variable. By analyzing physiological time series generated by control systems (e.g., the autonomic control of heart rate [1,2] or the somatic control of postural sway when standing upright [3,4]), researchers have discovered a preserved richness of the information carried by the output signals across multiple timescales. This richness in physiological signals can be assessed based on sample entropy [5], a measure of the irregularity of a time series obtained by calculating the probability that segments (also called vectors) of similar *m* samples remain similar when

the segment length increases to *m* + 1. Entropy-based complexity metrics relate to the information content of a signal by quantifying the degree of regularity or predictability over one or more scales of time. To address this issue, Costa et al. [1,2] have proposed a multiscale entropy (MSE) method that consists of a coarse-graining process and sample entropy computations to measure the complexity of a time series at different temporal scales.

The true strength of this method lies in considering the sample entropy value over multiple time scales rather than one unique scale. By considering many scales, one can evaluate how far a system deviates both from emitting white noise (meaning a degraded network organization) and emitting a very regular signal, which is interpreted as too strict an organization and a lack of flexibility.

In agreement with these interpretations, experimental applications have demonstrated a degraded entropy in cardiac and postural dynamics associated with frailty, aging, impairments, or diseases [1,3,4,6–19]. By contrast, high entropy is generally associated with an elevated capacity to adjust to an ever-changing environment [8], and elevated values are often observed in young healthy people [1].

During a dual-task protocol, the degradation of entropy in postural sway is exacerbated in aged people [3,8], thus indicating a failure in the dynamic re-organization of control. A similar phenomenon was observed in cardiovascular control when comparing nocturnal and diurnal MSEs of heart rate dynamics [1]. During waking periods, complexity raised in young individuals but vanished in old-age individuals, which lets the authors suppose that environmental stimuli (and the need for multi-tasking) may exceed a system's capacity, thus prohibiting an adequate re-organization in aged people.

One can ask whether stimuli not exceeding a system's capacity leads to an adequate re-organization of physiological control, and whether this is reflected in a greater signal entropy. In other words, it is unclear to date if the capacity to cope with a cognitive task in a healthy young to middle-age population is reflected in the entropy of a control system's output, while a degraded entropy seems to be the rule among old-aged individuals.

The aim of the present study is to assess the dynamic organization of control when performing cognitive tasks using the temporal behavior of heart rate and postural dynamics according to a multiscale entropy approach. We hypothesized that entropy would increase during the cognitive tasks, thus highlighting a flexible adaptation of neurophysiological control in our healthy participants.

#### **2. Materials and Methods**

#### *2.1. Population*

Thirty-four volunteers (8 women, 26 men) gave their written informed consent to participate in the present study in accordance with a local institutional review board policy and with the principles of the Declaration of Helsinki. The mean and standard deviation values of participants' age and body mass indexes were 30.5 ± 14.0 years (range: 18–59) and 21.1 ± 1.9 kg/m2, respectively. Among the women, four were using oral contraceptives, five reported being in the follicular phase of their menstrual cycle and three were in the luteal phase. All volunteers had a university education.

None of the participants reported neurological or physiological disorders. Participants were asked to avoid alcohol and caffeinated beverages for the 12 h preceding the experiment, but also to abstain from heavy physical activity.

#### *2.2. Protocol*

The experimental protocol included recordings of heart rate dynamics and postural dynamics, according to reference (Ref) and cognitive tasks (Cog). Recordings of heart rate dynamics lasted 10 min during which the participants were sitting down in a quiet environment, breathing normally (at a spontaneous rate), and either facing a blank computer screen (Ref), or performing cognitive tasks displayed on the screen (Cog). Recordings of postural dynamics lasted 51.2 s, during which the participants had to stand upright on a force platform, either looking at a black cross 4 m ahead

(Ref), or performing a cognitive task displayed on a screen 4 m ahead (Cog). This study followed a randomized crossover design in which participants executed either cardiac or postural measurements first, and, in each of these two blocks of measurements, either Ref or Cog was executed first.

#### *2.3. Recordings of RR Interval Time Series*

Cardiac interbeat (RR interval) time series were recorded from a bipolar electrode transmitter belt Polar H7 (Polar, Finland) fitted to the chest of the subject and connected to an iPod (Apple, Cupertino CA, USA) via Bluetooth. A smartphone application was used to continuously store the transmitted RR intervals. About 500–600 successive RR intervals were recorded over 10 min, the exact length of the RR interval time series depending on the average heart rate of each participant. For further analyses, the RR interval time series were exported to Matlab (Matworks, Natick, MA, USA).

#### *2.4. Recordings of Center of Pressure Time Series*

Anteroposterior (AP) and mediolateral (ML) postural sway was assessed from the center of pressure (COP) trajectory and recorded by a platform equipped with three strain gauges (Winposturo, Medicapteurs, 40 Hz/16b, Balma, France). Participants stood barefoot with feet abducted at 15◦ from the median line and heels separated by 4 cm. Participants' eyes were open and their arms hung loosely at their sides. COP trajectories were recorded at a sampling frequency of 40 Hz for 51.2 s (thus providing 2048 data points). The AP and ML time series were exported to Matlab (Matlab R2017b, Mathworks) for further analyses.

#### *2.5. Cognitive Tasks*

During Cog, participants performed cognitive tasks chosen to solicit frontal cortical lobes, cerebral areas where executive functions operate [20,21].

During the entire 10-min recordings of heart rate dynamics, participants performed four tests that followed one another in this order: the Stroop Color and Word Test (SCWT) [22], the Hayling Sentence Completion Test (HSCT) [23], a visual version of the Paced Auditory Serial Addition Test (PASAT) [24], and a semantic fluency task [25]. In order to ensure that participants remained silent during these tests, they wrote their answers to the test. The durations of each task were the following: 3 min for the SCWT, 2.5 min for the HSCT, 3 min for the PASAT, and 1.5 min for the semantic fluency task. SCWT is a task that forces inhibition of cognitive interference, which occurs when the processing of a stimulus feature affects the simultaneous processing of another attribute of the same stimulus [22]. The HSCT taps into response initiation and response inhibition [23]. The PASAT requires attentional functioning, working memory, and information processing speed [24]. The semantic fluency task consisted of spontaneous narration about a given topic (e.g., supermarkets) [25].

Due to the short duration of the recordings of postural dynamics (51.2 s), SCWT alone was administrated. Participants answered verbally.

#### *2.6. Analysis of RR Interval Time Series: Classic Indices*

Due to technical issues, two participants (one woman and one man) were excluded from the RR interval time series analyses. All computations were performed in Matlab using available functions and custom-designed routines. The raw data of heart rate variability (HRV; RR interval time series) were inspected for artifacts. Occasional ectopic beats (irregularity of the heart rhythm involving extra or skipped heartbeats such as extrasystole and consecutive compensatory pause), were visually identified and manually replaced with interpolated adjacent RR interval values. Classic indices were then calculated in time and frequency domains. The mean of RR interval values was calculated. The root mean square of successive differences (RMSSD) was obtained by calculating the first difference, a discrete analog of the first derivative, which is a standard method for removing slow varying trends in a signal and highlights the power of high-frequencies that are associated with parasympathetic modulations of the heart rate [26]. In the frequency domain, discrete Fourier transform was performed

after 4 Hz resampling using a cubic spline interpolation. The computation of signal power in fixed bands between 0.04 and 0.15 Hz for the low frequencies (LFs) and between 0.15 and 0.4 Hz for the high frequencies (HFs), allowed the calculation of the ratio LF/HF (an index of the sympathovagal balance) [26].

#### *2.7. Analysis of Center of Pressure Time Series: Classic Indices*

To evaluate the main features of postural control, here we computed the 95% confidence ellipse area, which is expected to enclose approximately 95% of the points on the COP path [19]. As well, the average velocity along the AP and the ML axes was computed. In the frequency domain, the spectral energy was assessed on ML and AP axes based on the power spectral density (PSD) obtained with fast Fourier transform.

#### *2.8. Analysis of Complexity: Entropy Indices*

The refined composite multiscale entropy (RCMSE) [27] was computed from both RR interval time series and postural time series in order to investigate signal complexity. As mentioned by Wu et al., the RCMSE method proposes improve the MSE method for short time series [2,27] by increasing the accuracy of entropy estimation and reducing the probability of inducing undefined entropy [27]. Undefined entropy may result from computations of short time series where no template segments (vectors) are matched to one another.

In brief, in the original MSE algorithm [1,2], the analyzed time series *x* = {*x*1, *x*2, ... , *xN*} is coarse grained using non-overlapping windows to obtain the representation of the original time series at different time scales τ. The algorithm detects how many segments (vectors) of size *m* remain similar at size *m* + 1 in the time series. Hence, the number of matched vector pairs indicates the level of signal regularity. Due to a reduction of the original signal by a factor of τ, the time series at large scale factors is composed of much fewer data points that the original one [27,28]. This is a concern for the accuracy of entropy calculation, mainly in short time series. A first attempt to address this accuracy concern was the development of composite multiscale entropy (CMSE) [29], whose main gain relies on considering all possible starting points at a given scale for the coarse-grained process, then calculating the averaged sample entropy for each scale. It was observed that CMSE, despite possessing a greater accuracy, increases the probability of inducing undefined entropy. To address this particular concern, Wu et al. (2014) [27] developed refined composite multiscale entropy (RCMSE), a method that uses the number of matched vector pairs for each scale factor τ and also for all (*k*) τ coarse-grained time series. Hence, it is unlikely even for short time series that the sum of matched vector pairs are zeros.

Briefly, the RCMSE algorithm consists of the following procedures (see detailed method in [27]):

$$R\text{CMSE}(\mathbf{x}, \ \mathbf{z}, \ m, \ r) = -\ln\left(\frac{\sum\_{k=1}^{\tau} n\_{k,\tau}^{m+1}}{\sum\_{k=1}^{\tau} n\_{k,\tau}^{m}}\right) \tag{1}$$

The length of the original time series determines the largest analyzed scale [1,27,31]. In this study, RCMSE was assessed over a range of scales from 1 to 4 for RR interval time series and over a range of scales from 1 to 14 for postural times series, a difference that was due to different sample sizes of RR interval (500 to 600 samples) and postural (2048 samples) times series.

The RCMSE curve is obtained by plotting entropy values for each coarse-grained time series as a function of scales. The cardiac entropy index (EC) and postural entropy index (EP) are the area under the corresponding RCMSE curves (areas calculated using the trapezoidal rule) (Figure 1) [1,27]. As recommended by Gow et al. [31], entropy indices were computed after pre-processing time series using empirical mode decomposition (EMD) [32]. EMD decomposes a signal into a sum of intrinsic mode functions (IMFs) and a residual trend. This residual trend was subtracted to remove the drift, which has been identified as a source of error in entropy assessments [31].

**Figure 1.** Cardiac entropy index (EC, **left**) and postural entropy index (EP, **right**), calculated from the areas under the refined composite multiscale entropy (RCMSE) curves.

We tested the hypothesis that the complexity of our time series is encoded in the sequential ordering, and that this ordering is not fortuitous. For that, we built surrogate time series by shuffling the sequence of data points (randomly reordering). RCMSE curves are presented comparatively (see the figure in Section 3.2).

#### *2.9. Statistical Analyses*

All statistical procedures were conducted by use of XLSTAT (Addinsoft, 2019, XLSTAT statistical and data analysis solution, Long Island, NY, USA). Classic and entropy indices were tested for normality (Shapiro-Wilk test). These indices were compared between Ref and Cog conditions (two-tail *t*-test or Wilcoxon test). Following the American Statistical Association statement on statistical significance and *p*-values, we did not base our scientific conclusions only on whether a *p*-value passes a specific threshold (usually, *p* < 0.05). Measures of detection sensitivity theory were additionally employed to assess sensitivity and specificity of the obtained indices, including the receiver operating characteristic (ROC) [33]. The area under the ROC curve indicates the probability that the index will assign a higher value to a positive instance than to a negative one [34]. Youden's index (*J* = *Sensitivity* + *Speci ficity* − 1) assesses the performance of the detector.

#### **3. Results**

Figure 2 shows typical signal outputs from the two explored neurophysiological systems obtained for a single participant: RR interval times series under reference (Ref) and cognitive (Cog) conditions are shown in the top panel; anteroposterior (AP) and mediolateral (ML) time series of the COP trajectory are reported below in middle and bottom panels respectively.

Mean values of classic and entropy indices derived from the signals obtained from our participants are reported in Table 1.

**Figure 2.** Top: RR interval time series from a representative participant in reference (Ref, **left**) and cognitive (Cog, **right**) conditions. Middle and bottom: anteroposterior (AP, **middle**) and mediolateral (ML, **bottom**) center of pressure (COP) time series, the horizontal axes are the same for these plots.

**Table 1.** Classic and entropy indices calculated from RR interval time series and from anteroposterior and mediolateral center of pressure time series, during reference and cognitive conditions.

Values provided are mean ± standard deviation. Ref: reference condition; Cog: cognitive condition; RMSSD: root mean square of successive differences; LFs: low frequencies; HFs: high frequencies; EC: cardiac entropy index; AP: anteroposterior; EP: postural entropy index; ML: mediolateral. Differences between Ref and Cog are expressed as \*\*\* *p* < 0.001, \*\* *p* < 0.01, \* *p* < 0.05.

#### *3.1. Classic Indices in Temporal and Frequency Domains*

The mean RR decreased (heart rate increased) under the Cog conditions (*p* < 0.001, two-tail Wilcoxon test).

None of the classic temporal (RMSSD) or frequency-derived heart rate variability (HRV) indices (LF, HF, LF/HF) differed between Ref and Cog, meaning that power at any given frequency did not change during Cog. Regarding posture, no difference in 95% confidence ellipse or total PSD-derived energy was observed in the COP displacement signals, while the COP velocity differed (AP *p* < 0.001, two-tail Wilcoxon test and ML *p* = 0.046, two-tail Wilcoxon test).

#### *3.2. Entropy Indices*

As expected, the RCMSE curves for the shuffled (randomly ordered) time series markedly differed from the RCMSE curves for the original time series (Figure 3). Entropy as a function of scales exhibited a monotonic decrease in shuffled time series, which is characteristic of random (white) noise [1,3]. By contrast, heart rate and postural dynamics exhibited typical behavior of a complex system, where the richness of carried information (as represented by entropy at a given scale) do not vanish when observed in longer timescales.

The main entropy index values (EC and EP) are presented in Table 1. As a main finding here, the EC index obtained during Cog was higher than the index obtained during Ref (*p* = 0.016, two-tail Wilcoxon test).

As well, along the AP axis where most of the postural (dys)regulation occurs [35,36], the EP index obtained during Cog was higher than the index obtained during Ref (*p* < 0.001, two-tail t-test). The ML EP indices did not differ between Ref and Cog (Table 1).

**Figure 3.** Refined composite multiscale entropy (RCMSE) analysis of RR interval time series (**left**) and center of pressure time series on anteroposterior axis (**right**) during reference (Ref) and cognitive (Cog) conditions. The RCMSE curves were obtained by connecting the group mean values of sample entropy for each scale. The error bars represent standard errors. The RCMSE curves for the surrogate shuffled time series are also presented.

#### *3.3. ROC Curves Analysis*

The ROC curves are shown in Figure 4, and the corresponding areas under the curves (AUC) and the Youden's indexes are reported in Table 2. The greatest AUC was obtained for entropy of both cardiac (0.67) and postural (0.72) time series, thus indicating that entropy showed a higher probability to assign a higher value to a positive instance than to a negative one.

**Figure 4.** Receiver operating characteristic (ROC) curves (sensitivity vs 1-specificity) for cardiac (**left**) and postural (**right**) indices. RMSSD: root mean square of successive differences; LF: low frequency; HF: high frequency; EC: cardiac entropy index; AP: anteroposterior; EP: postural entropy index; ML: mediolateral.

**Table 2.** Sensitivity analysis of cardiac and postural indices.

*J*: Youden's index; AUC: area under the ROC curve; RMSSD: root mean square of successive differences; LFs: low frequencies; HFs: high frequencies; EC: cardiac entropy index; AP: anteroposterior; EP: postural entropy index; ML: mediolateral.

#### **4. Discussion**

In this study we attempted to highlight the possible links between entropy measurements in two distinct neurophysiological networks and the systems complexity that probably facilitates the auto-organization and flexible adaptability in our healthy participants.

The main finding was that performing cognitive tasks resulted in a heightened entropy in heart rate and postural oscillations in young healthy people when compared to quiet conditions, as hypothesized. This may demonstrate that eliciting brain activity induced a remodeling in involuntary control networks, leading to a greater richness in signal information. This result is coherent with a great flexibility in our healthy young participants, which contrasts with a decline in entropy reported in older-aged individuals during a dual-task [3,8]. Both the elevation of entropy during cognitive tasks and the fact that two different neurophysiological systems behave in the same way represent original findings in the present study.

The link between central (cognitive) and peripheral regulations has been widely acknowledged. As a topic of growing interest, heart–brain interactions rely on a complex network of interconnected neural structures in the central autonomic network, whose functions are organized at the forebrain, brainstem, and spinal levels [37–41]. As shown by functional imaging, cortical and subcortical brain activities influence autonomic outflow to the periphery [42–45]. In our conditions, executive functions and associated prefrontal regions were involved during the imposed cognitive tasks. It is likely that the recruitment of brain regions reverberated throughout the autonomic outflow, as reflected in the heightened complexity revealed here by the RCMSE metrics in heart rate dynamics.

The rise in cardiac entropy is a marker of complex dynamics, which has been shown to reflect an underlying highly dimensional system with multiple interacting components associated with a high level of functionality [46,47]. Therefore, we can suggest that the observed increase in entropy during the cognitive tasks relies on remodeling and adaptability from the baseline, triggered by the recruitment and the interactions between brain components. This capacity to reorganize the control network in such a way that complexity is increased underscores a system's reserve that is not exhausted by any of our conditions [1]. This observation is in agreement with Costa et al. [1], who demonstrated that cardiac entropy (MSE) rose in healthy young people when facing diurnal challenges (waking period) that are absent during the night (sleep period). Cardiac entropy failed to increase comparatively in older-aged subjects. Other complexity metrics of HRV dynamics, such as fractal long-range properties in the temporal structure, provided additional evidence that cardiac complexity rises when the brain

performs executive functions, which was reflected in clearer 1/f noise [48]. Yet, entropy metrics may provide greater reliability for analyzing complexity from short-term HRV, because fractal properties are mainly dictated by power versus frequency characteristics of two dominant oscillators relying on vagal and sympathetic controls [49]. Hence, the "true fractal" component of the spectrum should be assessed only on frequencies < 0.04 Hz, which requires long-lasting RR interval time series recordings [50]. Noticeably, RCMSE provided satisfactory results for the presence of a complex (1/f) system's behavior in our conditions (10 min recordings).

MSE has traditionally been computed to study the COP trajectory as an index of complexity in the neurophysiological control of posture, and a number of recommendations have been very useful in this domain [31]. The pre-processing of the COP signal in the present study (EMD filtering) is part of the cautious approach that is recommended. While it is usually reported that dual-tasking provides a decline in entropy among older-age individuals, we clearly show in this study that COP entropy rose (rather than dropped) in our young healthy participants. This highlights an adaptive capacity when recruiting cognitive functions and their related brain regions, which contrasts with the degraded [3,8], but reversible [51], flexibility in older-aged dual-tasking.

It is not trivial to observe a similar behavior (the increase of entropy) in the present study both in relation to cardiovascular and postural control among our participants as a response to the cognitive task. These systems are markedly different; while the cardiac control relies on neurovisceral integration, the postural sway results from the somatosensory integration of exteroceptive and proprioceptive information. The rise in entropy therefore seems ubiquitous, and as such may reflect an adequate dynamic organization of neurophysiological control with improved interactions both within and between systems, whatever their neural structures.

Although the discovery of an increase in systems complexity in response to cognitive tasks is original in the present study, previous recent experiments have demonstrated that specific interventions may improve a degraded complexity. In humans, the capacity to restore a degraded postural complexity in aged people has been shown following mind–body interventions [4,7,9]. As well, walking arm-in-arm has recently been shown as an efficient way to restore walking complexity among older-aged individuals [52]. For years, degraded complexity markers (fractal or entropy metrics) in physiological signal outputs have been associated with impaired physiological control. The present study participates in the recent demonstrations of a heightened complexity marker indicating improved neurophysiological control.

#### **5. Conclusions**

By comparing quiet and cognitive task conditions, MSE-based metrics emphasize an adaptive systems capacity and a potential remodelling of cardiac and postural control systems under temporary states of cognitive tasks. The rise in entropy associated with cognitive functions, which contrasts with a decline reported in old people, illustrates improved interactions across brain regions and peripheral control loops, leading to a great richness in regulatory information. This demonstrates that the functional reserve capacity was not reached by our young healthy participants under our conditions. The issue of overwhelmed control systems in healthy young people confronted with cognitive tasks remained to be explored, through varying cognitive workloads or combining them with challenging emotions (e.g., stress), for example. It would be great to observe that whether, after heightening entropy in young people, more strenuous cognitive loads (with or without additional stressors) could push control systems to their adaptive limits, and whether this is reflected by a decline in entropy. It is unknown if the two distinct neurophysiological systems will keep demonstrating a similar behaviour when one faces such gradual challenges. With further study, even more credit could be gained towards entropy metrics and their capacity to faithfully reflect tight adjustments in complex physiological systems during gradual stimulations.

#### **6. Limitations**

Despite appealing results, the present study was not without limitations. The number of participants might have been augmented, in particular the number of females offering the opportunity to explore sexual dimorphism, as noted elsewhere [53]. Regarding gender, it was noted that even a methodological choice for MSE may influence physiological interpretations due to sex-related differences in cardiovascular dynamics [30]. While we used a fixed tolerance *r* at all scales in this study, an alternative method suggests adjusting the tolerance to the standard-deviation changes after coarse graining [30]. This might improve MSE estimation of heart rate and could be tested on the present data. It is presently unlikely that adopting an alternative (among many possible) usage of MSE could change the main conclusions of the present study; indeed, RCMSE on shuffle time series was computed here, clearly highlighting the distance from a random neurophysiological control and the capacity of RCMSE to distinguish quiet and cognitive task conditions (Figure 3). Finally, we have no explanation for the lack of change in ML entropy due to the cognitive task during postural regulation. Further studies are needed to explore the potential role of certain instances that could dominantly aggregate AP information, making complex AP regulations more responsive than ML.

**Author Contributions:** Conceptualization, E.B. and V.D.-A.; Methodology, E.B. and V.D.-A.; Software, E.B., L.M.A., P.G. and V.D.-A.; Validation, E.B., L.M.A., P.G. and V.D.-A.; Formal analysis, E.B.; Investigation, E.B.; Resources, E.B., L.M.A., P.G. and V.D.-A.; Data curation, E.B.; Writing—Original draft preparation, E.B., L.M.A., and V.D.-A.; Writing—Review and editing, E.B., L.M.A., P.G. and V.D.-A.

**Funding:** This research received no external funding.

**Acknowledgments:** The authors thank Yoel Kidane for reviewing the English manuscript.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**

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*<IP_ADDRESS>.1 Tetrodotoxin*

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