Dina H. El-Hammady

Effect of Anodal Versus Cathodal Transcranial Direct Current Stimulation on Stroke Rehabilitation A Pilot Randomized Controlled Trial

Objective. We compared the long-term effect of anodal versus cathodal transcranial direct current stimulation (tDCS) on motor recovery in patients after subacute stroke. Methods. Forty patients with ischemic stroke undergoing rehabilitation were randomly assigned to 1 of 3 groups: Anodal, Cathodal (over-affected and unaffected hemisphere, respectively), and Sham. Each group received tDCS at an intensity of 2 mA for 25 minutes daily for 6 consecutive days over of the motor cortex hand area. Patients were assessed with the National Institutes of Health Stroke Scale (NIHSS), Orgogozo’s MCA scale (OMCASS), the Barthel index (BI), and the Medical Research Council (MRC) muscle strength scale at baseline, after the sixth tDCS session and then 1, 2, and 3 months later. Motor cortical excitability was measured with transcranial magnetic stimulation (TMS) at baseline and after the sixth session. Results. By the 3-month follow-up, all groups had improved on all scales with P values ranging from .01 to .0001. Improvement was equal in the Anodal and Cathodal groups. When these treated groups were combined and compared with Sham, significant interactions were seen for the OMCASS and BI scales of functional ability (P = .002 for each). There was increased cortical excitability of the affected hemisphere in all groups with the changes being greater in the real versus sham groups. There were borderline significant improvements in muscle strength. Conclusion. A brief course of 2 types of tDCS stimulation is superior to sham stimulation in enhancing the effect of rehabilitation training to improve motor recovery after stroke.

Dual-Hemisphere Repetitive Transcranial Magnetic Stimulation for Rehabilitation of Poststroke Aphasia: A Randomized, Double-Blind Clinical Trial

Background. Recent neuroimaging studies on poststroke aphasia revealed maladaptive cortical changes in both hemispheres, yet their functional contribution in language recovery remains elusive. The aim of this study was to evaluate the long-term efficacy of dual-hemisphere repetitive transcranial magnetic stimulation (rTMS) on poststroke aphasia. Methods. Thirty patients with subacute poststroke nonfluent aphasia were randomly allocated to receive real or sham rTMS. Each patient received 1000 rTMS pulses (1 Hz at 110% of resting motor threshold [rMT] over the right unaffected Broca’s area and 1000 pulses (20 Hz at 80% rMT) over the left affected Broca’s area for 10 consecutive days followed by speech/language training. The language section of the Hemispheric Stroke Scale (HSS), the Stroke Aphasic Depression Questionnaire–Hospital Version (SADQ-H), and the National Institutes of Health Stroke Scale (NIHSS) were measured before, immediately after the 10 sessions, and 1 and 2 months after the last session. Results. At baseline, there were no significant differences between groups in demographic and clinical rating scales. However, there was a significantly greater improvement in the HSS language score as well as in the SADQ-H after real rTMS compared with sham rTMS, which remained significant 2 months after the end of the treatment sessions. Conclusion. This is the first clinical study of dual-hemisphere rTMS in poststroke aphasia. Combining dual-hemisphere rTMS with language training might be a feasible treatment for nonfluent aphasia; further multicenter studies are needed to confirm this result.

A double-blind randomized clinical trial on the efficacy of magnetic sacral root stimulation for the treatment of Monosymptomatic Nocturnal Enuresis

Abstract Purpose: Purpose of this study was to evaluate the long term efficacy of repetitive sacral root magnetic stimulation (rSMS) in patients with monosymptomatic nocturnal enuresis (MNE). Methods: Forty four patients were randomized to receive either sham or real repetitive sacral root magnetic stimulation (rSMS; 15 Hz with a total of 1500 pulses/session) for 10 sessions. Evaluation was performed before starting treatment, immediately after the 5th and 10th treatment session, and 1 month later, using frequency of enuresis/week, visual analogue scale (VAS) and quality of life as outcome measures. Resting and active motor thresholds of gastrocnemius muscles were measured before and after the end of sessions. Results: Both treatment and control groups were comparable for baseline measures of frequency of enuresis, and VAS. The mean number of wet nights/week was significantly reduced in patients who received real rSMS. This improvement was maintained 1 month after the end of treatment. Patients receiving real-rSMS also reported an improvement in VAS ratings and quality of life. A significant reduction of resting motor threshold was recorded after rSMS in the real group while no such changes were observed in the sham group. Conclusion: These findings suggest that rSMS has potential as an adjuvant treatment for MNE and deserves further study.

Repetitive Lumbosacral Nerve Magnetic Stimulation Improves Bladder Dysfunction Due to Lumbosacral Nerve Injury A Pilot Randomized Controlled Study

Background. Rapid rate magnetic stimulation of human sacral nerve roots can reduce stress incontinence. Objective. To test stimulation for urgency incontinence due to lumbosacral plexopathy. Methods. The authors studied patients with intractable neurogenic urinary dysfunction due to lumbosacral nerve injuries. Eligible patients were randomized to receive either real or sham repetitive lumbosacral magnetic stimulation (rLMS; 15 Hz with a total of 1500 pulses/session) for 10 sessions. Evaluation was performed before starting treatment, immediately after the 5th and 10th treatment session, and 1 month later, using rating scales to score urinary dysfunction and a visual analogue scale (VAS) to assess lower back pain. Posterior tibial nerve F-wave and H-reflexes were tested before and after treatment. Results. Both treatment and control groups were comparable for baseline characters and sphincteric disturbances. The mean number of voids and incontinence per 24 hours was significantly reduced in patients who received rLMS. The improvement was maintained 1 month after the end of treatment. Patients receiving real-rLMS also reported an improvement in VAS ratings. Improvement in F-wave and H-reflex latencies after real stimulation (P = .002 and P = .036, respectively) was found as well. Conclusion. rLMS at 15 Hz may improve urinary dysfunction secondary to lumbosacral nerve injury. Further trials can determine the profile of patients who may benefit and optimal stimulation parameters.

High-resolution manometry compared with the University of California, Los Angeles Scleroderma Clinical Trials Consortium GIT 2.0 in Systemic Sclerosis

OBJECTIVES To study esophageal high resolution manometry (HRM) in systemic sclerosis (SSc) patients and the correlation of findings to The University of California, Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 (UCLA SCTC_GIT 2.0). METHODS Forty SSc patients were administered to the UCLA SCTC GIT 2.0. Patients underwent HRM study (Solar GI MMS). HRM data were compared with 15 healthy volunteers. RESULTS Forty patients with mean age 46 ± 7 years and disease duration 9.3 ± 7 years reported upper (85.7%), lower GI symptoms (75%), while 5% reported no symptoms. Mean ± SD scores of UCLA SCTC_GIT 2.0 items were as follows: reflux 1.2 ± 0.8, distention 1.6 ± 1.2, fecal soiling 0.3 ± 0.9, diarrhea 0.8 ± 1, social 1 ± 1, emotional 1 ± 1.1, constipation 0.5 ± 0.9, and total GIT score 0.9 ± 0.6. Lower esophageal sphincter (LES) pressure and distal esophageal amplitude were significantly lower in SSc patients than controls. Main manometric findings were decreased LES resting pressure (40%) and aperistalsis (40%). Regression analyses showed distal esophageal amplitude and LES resting pressure negatively correlated with reflux score (r = -0.64; p = 0.001 and r = -0.46; p = 0.019, respectively), and total GIT score (r = -0.54; p = 0.007 and r = -0.42; p = 0.03, respectively). LES resting pressure had negative correlations with diarrhea score (r = -0.062; p = 0.002). CONCLUSIONS Decreased distal esophageal amplitude encountered as hypoperistalsis or even aperistalsis was associated with increased reflux and GIT scores (negatively correlated) UCLA SCTC_GIT 2.0 questionnaires. The GIT2.0 is easy to use and can serve as an indicator that further testing of the GI tract, including the esophagus, is indicated.

Steroid/Antiviral for the treatment of Bell's palsy: Double blind randomized clinical trial.

BACKGROUND A large number of patients with Bells palsy fail to recover facial function completely after steroid therapy. Only a few small trials have been conducted to test whether outcomes can be improved by the addition of antiviral therapy. OBJECTIVE To evaluate the efficacy of treatment with steroid alone versus steroid + antiviral in a group of patients with moderately severe to severe acute Bells palsy. METHODS Fifty eligible patients out of a total of 65 with acute onset Bells palsy were randomized to receive the two treatments. Evaluation was performed before starting treatment, after 2 weeks of treatment and 3 months after onset, using the House and Brackmann facial nerve grading system (HB) and the Sunnybrook grading system.This study was registered with ClinicalTrials.gov, number NCT02328079. RESULTS Both treatments had comparable demographics and clinical scores at baseline. There was greater improvement in the mean HB and Sunnybrook scores of the steroid + antiviral group in comparison to steroid group at 3 months. At the end of the 3rd month, 17 patients (68%) had good recovery and 8 patients (32%) had poor recovery in the steroid group compared with 23 patients (92%) and 2 (8%) respectively in the steroid and antiviral group (p = 0.034). CONCLUSION The combination of steroid and antiviral treatment increases the possibility of recovery in moderately severe to complete acute Bells palsy.

Prognostic role of neurophysiological testing 3–7 days after onset of acute unilateral Bell's palsy

OBJECTIVE Recovery from acute Bells palsy (BP) is variable and there are few predictors of response. We evaluated the usefulness of a range of neurophysiological parameters to predict outcome in BP. METHODS Fifty-nine patients (age: 33.7±15.4 years) with acute unilateral BP were recruited within 3-7 days of onset. They were evaluated with electroneurography, facial nerve excitability, and the blink reflex. House-Brackmann (HB) clinical scores were obtained at the same time and three months later. All patients received prednisolone treatment and regular rehabilitation. RESULTS At three months, 41 patients (69.5%) had good recovery, while 18 patients (30.5%) had poor recovery according to the HB scale. The facial nerve excitability threshold and threshold difference between sides were significantly lower in patients with good recovery than those with poor recovery (P values=0.022 and 0.006 respectively). Facial nerve degeneration rate (1 - affected/unaffected amplitude of CMAP of muscle ×100%) recorded in frontalis (P=0.002) and orbicularis oris (P=0.038) were also smaller in good recovery than poor recovery patients. There were no differences in latency and amplitude of CMAPs recorded from frontalis or orbicularis oris muscle, nor in latencies of the components of the blink reflex. ROC analysis showed that patients who had a threshold side difference <13mA (35 cases), had a higher chance of good recovery (85.7% versus 14.3% poor recovery). Patients who had a degeneration rate<50% (38 cases) also had a higher chance of good recovery (78.9%) versus 21.1% who had poor recovery, while patients with a degeneration rate>50% (21 cases) had a 47.8% chance of good recovery versus 52.2% poor recovery (P=0.004). Logistic regression analysis showed that the most significant predictive indicator of BP recovery was the facial nerve degeneration rate of frontalis muscle (P=0.011). CONCLUSION Facial nerve degeneration rate of frontalis muscle provides the most sensitive prognostic indicator of recovery from acute BP and may provide useful management strategies.

Clinical and subclinical neuropsychiatric abnormalities in rheumatoid arthritis patients

Background Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease with probable autoimmune aetiology. RA has many secondary complications and a variety of neuropsychological consequences. Aim The aim of this study was to estimate the frequencies of neuropsychiatric disorders in RA patients and their relationship with the duration and activity of disease. Patients and methods Seventy-four consecutive female RA patients were recruited and compared with 25 age-matched and education status-matched female healthy volunteers. All eligible participants underwent clinical, laboratory and electrophysiological examinations (motor and sensory nerve conduction study, F-wave of four limbs, P300 event-related potential and electroencephalography). The Structured Clinical Interview for Diagnostic and statistical manual of mental disorders, 3rd ed., Revised (DSM-III-R) Axis I Disorders (SCID-I) for diagnosis of psychiatric illness and the Wechsler Adult Intelligence Scale, 3rd ed. (WAIS-III) with assessment of total scale, verbal and performance intelligence quotients (IQ) were administered to all participants. Results Fourteen (18.9%) patients had evidence of symptomatic peripheral neuropathy and radiculopathy, whereas 60.8% had psychiatric disorders. Depression was the most prevalent psychiatric disorder (45%), followed by anxiety (27%) and comorbid anxiety with depression (21.6%). Low IQ scores were recorded in 54% of patients. P300 latency was significantly prolonged (P = 0.0001), and seven (9.5%) RA patients recorded abnormal P300 latency (>mean ± 2 SD) compared with control values. Abnormal electroencephalography findings were observed in 48.6%. Visual analogue scale pain score was significantly higher among patients with psychiatric disorders versus patients without psychiatric disorders (P = 0.0001). Significant negative correlation was recorded between Disease Activity Score and total IQ score (P = 0.01), whereas no significant association was seen between Disease Activity Score and the presence of neuropathy or psychiatric disorders. Conclusion Cognitive impairment, depression, anxiety and peripheral neuropathy are common in RA patients. Early diagnosis and management of neuropsychiatric disorders in RA patients may greatly improve the patients′ health-related quality of life.