Effect of high frequency repetitive transcranial magnetic stimulation (rTMS) on the balance and the white matter integrity in patients with relapsing-remitting multiple sclerosis: A long-term follow-up study.

OBJECTIVES: Repetitive Transcranial Magnetic Stimulation (rTMS) is considered as a safe and non-invasive developing technique used as a therapeutic method for patients with Relapsing-Remitting Multiple Sclerosis (RRMS) who suffer from disturbances in gait and balance. The aim of our study is to evaluate the long-term effect of high frequency rTMS as a therapeutic option for truncal ataxia in RRMS patients and to assess its impact on the integrity of the white matter (WMI), measured in the form of anisotropy metrics using diffusion tensor imaging (DTI). METHODS: The study was conducted in two phases: phase I; a randomized, single-blind, sham-controlled phase and phase II was a 12 months longitudinal open-label prospective phase. Phase I of the trial involved the randomization of 43 patients with RRMS and truncal ataxia to either real (n = 20) or sham (n = 19) rTMS (2 participants from each treatment group were excluded from the study; one developed a relapse before treatment, 2 declined to participate, and one did not show up). Phase II involved providing 12 actual treatments cycles to all patients; each cycle length is 4 weeks, repeated four times on a trimonthly basis, forming a total of 48 sessions. DTI was used for assessment of the WMI. All patients performed DTI 3 times: Imaging sessions were conducted at the screening visit, at the end of phase I, and after the last session in phase II for the first, second and third sessions respectively. A figure-of-8-shape coil, employing rTMS protocol and located over the cerebellum, was used. rTMS protocol is formed of 20 trains formed of 50 stimuli with 20 s apart (5 Hz of 80 % of resting Motor Threshold "MT"). The Berg Balance Scale (BBS), Time up and go (TUG) test, and 10-m walk test (10MWT) were first evaluated at the start of each cycle and just after the final rTMS session. RESULTS: The genuine rTMS group's 10MWT, TUG, and BBS showed substantial improvement (p < 0.01), which is continued to be improved throughout the study Timeline, with a significant difference observed following the final rTMS session (P< 0.001). A longitudinal increase in FA was observed in both the Cerebello-Thalamo-Cortical (CTC) and Cortico-Ponto-Cerebellar (CPC) bilateral, as indicated by means of Fractional Anisotropy (FA) measures (p < 0.05). CONCLUSION: In ataxic RRMS patients, high frequency rTMS over the cerebellum has a long-term beneficial impact on both balance and WMI.

Brain aging in a sample of normal Egyptians cognition, education, addiction and smoking.

The impact of duration of education, cannabis addiction and smoking on cognition and brain aging is studied in 211 normal Egyptian volunteers with mean age 46.4+/-3.6 years (range: 20-76 years). Subjects were classified into two groups: Gr I (non-addicts) with 174 subjects, mean age 49.9+/-3.8 years (range 20-76 years), smokers and non-smokers, educated and non-educated and Gr II (cannabis addicts) with 37 subjects, mean age 43.6+/-2.6 years (range 20-72 years) all smokers, educated and non-educated. Outcome measures included the Paced Auditory Serial Addition test (PASAT) for testing attention and the Trailmaking test A, and B (TMa and TMb) for testing psychomotor performance. Age correlated positively with score of Trailmaking test (TMb) in the non-addict group and in the addict group (TMa and TMb). Years of education correlated negatively with scores of Trialmaking test (TMb) in the non-addict group (Gr I) but not the addict group (Gr II). However, in both groups mean scores of the Trailmaking test (TMa) were significantly lower in subjects with a primary level of education than those with higher levels of education. No significant difference was detected between male smokers and nonsmokers of Gr I (non-addicts) regarding any of the neuropsychological tests. Yet, smokers and the non-educated group had poorer attention compared to non-smokers of the same group. Cannabis addicts (Gr II) had significantly poorer attention than non-addict normal volunteers (Gr I). It is concluded that impairment of psychomotor performance is age related whether in normal non-addicts or in cannabis addicts. A decline in attention was detected in cannabis addicts and has been considered a feature of pathological aging. Education in early life as well as the duration of education are neuroprotectors for brain aging more so in the non-addict than addict group. Though cigarette smoking per se has no effect on cognitive abilities in normal aging, it becomes evident that its association with lack of education impairs attention.

Brain aging in normal Egyptians: neuropsychological, electrophysiological and cranial tomographic assessment.

Eighty-eight normal Egyptian volunteers above the age of 40 years were studied for brain aging and subjected to neuropsychological (the Paced Auditory Serial Addition Test; the Trailmaking test A, B; the Digit Symbol Substitution Test; sensory and secondary memory tests), electrophysiological (computerized EEG, P300 and reaction time measures), and Computerized Cranial Tomography (CCT) assessment. A significant correlation was found between age and both perception (Digit Symbol Substitution Test (DDST) and psychomotor performance (Trailmaking B test (TMb)), reaction time (RT) and the size of the third ventricle. Whereas females were worse in attention (Paced Auditory Serial Addition Test (PASAT)), males had worse performance in secondary memory test. Elderly subjects with vascular risk factors did worse in psychomotor performance (TMa) than subjects with no risk factors. Non-educated subjects showed worse perception (DSST) than educated subjects. A significant decrease in upper and lower limit percent power of the alpha band was found in subjects above 60 years, males, and non-educated subjects. A significant increase in theta activity was found only in non-educated subjects. It is concluded that decline in specific cognitive functions occurs with advancing age. Vascular risk factors and lack of education early in life enhance these changes. Moreover, the EEG slowing in the elderly was linked to lack of education early in life.

Cognitive deficits in ischemic strokes: psychometric, electrophysiological and cranial tomographic assessment.

Global and specific cognitive functions were assessed in 57 patients with ischemic strokes subjected to clinical neuropsychiatric, psychometric, electrophysiological and cranial tomographic evaluation. Patients did significantly worse than normal controls in the Blessed dementia scale, Sandoz clinical assessment geriatric scale but not the Folstein mini-mental state examination. Of the specific cognitive functions, attention and psychomotor performance were significantly impaired in stroke patients when compared to normal controls. The impairment in global cognitive functions, attention and psychomotor performance was more evident in chronic than acute cases. Increasing age correlated positively to the deterioration in psychomotor performance and perception. Cranial tomographic size of infarction was significantly related to global cognitive as well as intentional (sensory) memory impairment. The more marked the conventional electroencephalographic abnormalities, the more impaired were the global cognitive functions. High limit of the theta percent power correlated positively to deterioration in psychomotor performance. All P300 parameters except amplitude correlated significantly with impairment of global cognitive function and psychomotor performance in stroke patients.