[What is needed for rTMS to become a treatment?]. / Que manque-t-il à la rTMS pour devenir une thérapie?

Repetitive trans-cranial magnetic stimulation (rTMS) can modulate cortical excitability. Consequently, it appears appealing for the treatment of some affections such as depression or hallucinations. There is already some proof that the concept is valid, but rTMS is slow in progressing in the therapeutic field as a true armamentum. Indeed its effects are of short duration and even inconstant from one patient to the next. These drawbacks depend on certain factors that we will discuss. Until now, there has been inadequate control of the stimulation site. It is possible that this site could vary on an individual basis. It seems logical to propose the use of functional imaging for such a purpose, but its use should be adapted to the symptom. Even after localizing the site, the coil has to be placed accurately. This could be facilitated by a neuronavigator. Stimulation protocols are currently defined by three parameters: the frequency modulating the cortical action either as a stimulation (>5 Hz) or an inhibition (<1 Hz), the intensity and the number of stimuli influencing, notably, the amplitude and duration of the effect. Unfortunately, the effect is inconstant in a given patient and paradoxical reactions have been observed in more than 15% of normal individuals. Improved reliability and amplification of the effect rely on the better control of other parameters: pattern of stimulation, pre and post-conditioning, state of the cortex during stimulation, associated medications, endogenous idiosyncratic factors and related pathology. We will review the current physiological literature to discuss the possible options that would constitute a rational basis for setting up more efficient protocols.

Rehabilitation of executive functions in a real-life setting: goal management training applied to a person with schizophrenia.

The aim was to assess the efficacy of a modified version of Goal Management Training (GMT) in a person with schizophrenia who had difficulties in attaining the final goal for new and multitasking daily-life situations. GMT is designed to improve abilities in establishing goal-directed plans and carrying them out effectively. Beneficial effects of GMT were measured for several clinical questionnaires, laboratory tasks, and three real-life situations: meal preparation (trained, familiar); washing (nontrained, familiar); meeting preparation (nontrained, unfamiliar). The results revealed improvement in planning and on trained laboratory and meal preparation tasks and a generalization of GMT effects on nontrained laboratory and everyday tasks. Self-esteem also improved. Finally, a two-year followup indicated the durability of the beneficial effects.

An individualized and everyday life approach to cognitive rehabilitation in schizophrenia: a case illustration.

Objective. The effectiveness of an individualized and everyday approach to cognitive rehabilitation for schizophrenia was examined in a case study. Method. After cognitive and functional assessment, concrete objectives were targeted for the person's everyday complaints. Strategies were constructed based on an analysis of the cognitive profile, daily life functioning, and processes involved in activities. They included a memory strategy for reading, a diary to compensate memory difficulties, and working memory exercises to improve immediate processing of information when reading and following conversations. Efficacy was assessed with outcome measures. Results. The program had beneficial effects on the person's cognitive and everyday functioning, which persisted at a 3-year follow-up. Conclusion. Findings provide suggestive evidence that an individualized and everyday approach may be a useful alternative in order to obtain a meaningfully lasting transfer of training to daily life, compared to the nomothetic ones which dominate the field.

Cognitive rehabilitation of the updating sub-component of working memory in schizophrenia: a case study.

Working memory problems have been identified as a core cognitive deficit in schizophrenia. In this paper, we present the results of a cognitive rehabilitation programme (Duval & Coyette, 2005) administered to a schizophrenia patient, and specifically designed to improve the updating sub-component of working memory. The original feature of this programme was that it involved two types of updating exercises: cognitive and ecological. The purpose was to enable the patient to acquire cognitive strategies that alleviate the mental load of the central executive and to transfer them to daily life. The specificity and efficacy of the programme were assessed with multiple (cognitive, ecological and non-target) baseline measurements. In addition, several questionnaires were administered to assess the effect of the programme on subjective cognitive complaints affecting daily life, psychiatric symptoms and self-esteem. The results demonstrated the efficacy of the rehabilitation programme on the updating function and the generalisation of these beneficial effects to daily life. A significant decrease in both subjective cognitive complaints and psychiatric symptoms was also observed. However, the patient's self-esteem did not improve.