Gharib Fawi

Recovery of upper-limb function due to enhanced use-dependent plasticity in chronic stroke patients

Patients with chronic stroke often show increased flexor hypertonia in their affected upper limbs. Although an intervention strategy targeting the extensors of the affected upper limb might thus be expected to have benefits for functional recovery, conventional repetitive motor training has limited clinical utility. Recent studies have shown that repetitive transcranial magnetic stimulation could induce motor recovery. The present study tested whether 5u2009Hz repetitive transcranial magnetic stimulation of the upper-limb area of the primary motor cortex, combined with extensor motor training, had a greater effect on motor recovery than either intervention alone in stroke hemiparesis. Nine patients with chronic subcortical stroke and nine age-matched healthy subjects completed the crossover study. In separate sessions, we examined the single intervention effect of repetitive wrist and finger extension exercises aided by neuromuscular stimulation, the single intervention effect of 5u2009Hz repetitive transcranial magnetic stimulation and the combined effect of the two interventions. The motor functions were evaluated behaviourally in patients (Experiment 1) and electrophysiologically in healthy subjects (Experiment 2), both before and after the intervention. In addition, we tested the long-term effect by repeating the combined interventions 12 times in patients (Experiment 3). The motor functions were measured again 2 weeks after the end of the repetitive intervention period. In Experiment 1, the combined intervention, but neither of the single interventions, resulted in an improvement of extensor movement (Pu2009<u20090.0001) and grip power (Pu2009<u20090.05), along with a reduction of flexor hypertonia (Pu2009<u20090.01), in their paretic upper limbs. In Experiment 2, only the combined intervention resulted in selective plastic changes of cortico-spinal excitability (Pu2009<u20090.01), motor threshold (Pu2009<u20090.001) and silent period (Pu2009<u20090.01) for the extensors. In Experiment 3, we also confirmed long-term beneficial effects of the combined intervention in patients. These findings indicate that combining motor training with repetitive transcranial magnetic stimulation can facilitate use-dependent plasticity and achieve functional recovery of motor impairments that cannot be attained by either intervention alone. This method could be a powerful rehabilitative approach for patients with hemiparetic stroke.

Movement-Related Cortical Stimulation Can Induce Human Motor Plasticity

Repeated paired associative stimulation combining peripheral nerve stimulation and transcranial magnetic stimulation (TMS) of the primary motor cortex (M1) can produce human motor plasticity. However, previous studies used paired artificial stimuli, so that it is not known whether repetitive natural M1 activity associated with TMS can induce plasticity or not. To test this hypothesis, we developed a movement-related cortical stimulation (MRCS) protocol, in which the left M1 was stimulated by TMS at specific timing with respect to the mean expected reaction time (RT) of voluntary movement during a simple reaction time task using the right abductor pollicis brevis (APB) muscle. Seventeen normal volunteers were subjected to repeated MRCS intervention (0.2 Hz, 240 pairs). Motor function was assessed before and after MRCS. When TMS was given 50 ms before the RT of movement [MRCS(−50)], motor-evoked potential (MEP) amplitude of the right APB, but not other muscles, increased for up to 15 min post-MRCS. The RT of the right APB was also shortened. However, spinal excitability measured by F-wave did not change. When TMS was given 100 ms after the RT [MRCS(+100)], MEP amplitude was decreased. These findings show that this new MRCS protocol can produce timing-dependent motor associative plasticity, which may be clinically useful.

Momentary reward induce changes in excitability of primary motor cortex.

OBJECTIVEnTo investigate the human primary motor cortex (M1) excitability changes induced by momentary reward.nnnMETHODSnTo test the changes in excitatory and inhibitory functions of M1, motor-evoked potentials (MEPs), short-interval intracortical inhibition (SICI) and short-latency afferent inhibition (SAI) were tested in the abductor pollicis brevis (APB) muscle of non-dominant hand in 14 healthy volunteers by transcranial magnetic stimulation (TMS) during a behavioral task in which subjects were pseudorandomly received either reward target or non-target stimuli in response to a cue. To control sensorimotor and attention effects, a sensorimotor control task was done replacing the reward target with non-reward target.nnnRESULTSnThe SICI was increased, and the SAI was decreased significantly during the presentation of the reward target stimuli. Those changes were not evident during non-reward target stimuli in the sensorimotor control task, indicating that this change is specific to momentary reward.nnnCONCLUSIONSnMomentary rewarding is associated with change in intracortical inhibitory circuits of M1.nnnSIGNIFICANCEnTMS may be a useful probe to study the reward system in health and in many diseases in which its dysfunction is suspected.

Prevalence of ischemic and hemorrhagic strokes in Qena Governorate, Egypt: community-based study.

BACKGROUNDnStroke is a major health problem in developing countries. In a previous survey, the prevalence rate of stroke in the Nile Valley governorate of Assiut wasxa0significantly higher than other Arabic countries. In view of this, we carried out a follow-up study in a second Nile Valley governorate (Qena).nnnMETHODSnA community-based, three-phase, door-to-door study with random sampling of 10 areas in Qena governorate (first phase), involving 8027 inhabitant with 4172 males (51.97%) and 3855 females (48.03%). There were 4427 urban residents (55.15%) and 3600 residents (44.85%) from the rural community. In the second phase, participants were screened using the questionnaire for stroke, whereas the third phase involved neurologic evaluation of all suspected cases, with diagnosis of stroke confirmed by evaluation of computed tomography (CT) scans. The Mini Mental State Examination and National Institute of Health Stroke Scale were evaluated for each patient.nnnRESULTSnOf the 8027 participants, 74 were identified as positive cases with a crude prevalence rate 922 of 100,000, an age-adjusted local prevalence rate of 777 of 100,000 and an age-adjusted prevalence rate of Egyptian population 566.6 of 100,000. The highest age-specific prevalence rates were recorded among subjects 70xa0years of age or older (8,392 of 100,000). The crude prevalence rate of ischemic stroke was significantly higher than that of hemorrhagic stroke (797 vs 125 of 100,000). Illiterate participants had a significantly higher crude prevalence rate than those who were literate (3567 vs 704 of 100,000). There was no significant difference in the prevalence rate between rural and urban areas or between males and females. Fifty patients (67.57%) had 1 or more risk factors of stroke, with hypertension being the most common (62.16%), followed by diabetes mellitus (36.49%).nnnCONCLUSIONSnThe overall prevalence rate of stroke is nearly the same as in other Egyptian governorates and is higher than other Arabic countries.

Prevalence of mild cognitive impairment and dementia among the elderly population of Qena Governorate, Upper Egypt: a community-based study.

BACKGROUNDnThere are only a few reports which provide prevalence rates of mild cognitive impairment (MCI) and dementia specifically in Arabic countries.nnnOBJECTIVEnThis study is aimed at estimating the prevalence of MCI and dementia among subjects aged ≥60 years using door-to-door survey in Qena Governorate/Egypt.nnnMETHODSnWe conducted a door-to-door survey with multistage probability random sampling. Screening of all subjects aged ≥60 years (n = 691) employed a simple questionnaire including changes in memory, behavior, and daily activity, Memory and Executive Screening test (MES)as well as the Mini-Mental State Examination. Suspected cases were referred to the hospital for full clinical examination, DSM-IV diagnostic criteria, Hachinski Ischemic Score, neuroimaging, and laboratory investigations if indicated.nnnRESULTSnOf the 691 participants, 12 cases had MCI, giving a crude prevalence rate (CPR) of 1.74/100 and 35 were identified as positive for dementia with a CPR of 5.07/100. The highest age-specific prevalence rates were recorded among subjects ≥85 years old (100/100). The CPRs were significantly higher in urban than rural areas (7.1 versus 3.27/100, respectively; p = 0.03), in industrial areas than non-industrial areas (13.23 versus 1.99; p = 0.00001), and in illiterate than literate participants (10.12 versus 2.25/100; p = 0.00001).nnnCONCLUSIONnOverall, the prevalence rate of MCI and dementia were lower in Qena/Egypt than in other countries. Advanced age, illiteracy, and living in an industrial area were found to be associated with dementia.

Prevalence of Diabetes and Diabetic Neuropathy in Qena Governorate: Population-Based Survey.

Background: No previous study was done to estimate the prevalence of diabetic neuropathy (DN) in Arabic countries. The aim of this study was to estimate the prevalence of DN and its characteristics in Qena governorate. Material and Methods: This is a random sampling of 10 study areas, involving 9,303 inhabitants; 51.1% men and 48.9% women were recruited. There were 57.3% urban residents and 42.7% rural residents. Patients were diagnosed using a screening questionnaire for diabetes mellitus (DM) as well as for DN in addition to measuring blood sugar in suspected cases. All positive cases were referred to Qena University Hospital and were subjected to full clinical, electrophysiological and laboratory investigations. Results: Out of 9,303 people screened, 837 were diabetic giving prevalence 8.99% of the population. Eight hundred eleven had type II DM and 26 cases had type I giving prevalence of 8.7 and 0.3%, respectively. One hundred fifty-five out of 837 (18.5%) diabetic patients had evidence of DN with prevalence rate being 1.7% of the total population. Diabetic polyneuropathy was the commonest type with prevalence 1.5%. The prevalence of DN was higher in women than in men. Rural residents had significantly higher prevalence of DN compared to urban residents (1.9 vs. 1.4) and illiterate population more than educated (5.8 vs. 1.2). Conclusion: The overall crude prevalence rate of DM and DN is nearly the same as in European countries and lower than that in other Arabic countries.

Community-based epidemiological study of epilepsy in the Qena governorate in Upper Egypt, a door-to-door survey.

BACKGROUNDnThe aim of this study is to estimate the epidemiological features of epilepsy in a representative governorate of Upper Egypt.nnnMATERIALS AND METHODSnA door-to-door community-based survey study was performed using a sample of 10 areas among various districts of the Qena governorate in Upper Egypt. Six were classified as rural areas, and the remaining four were classified as urban areas, with a total population of 8027 inhabitants. The population was screened using an epilepsy-screening questionnaire. Positive cases with suspected epilepsy were referred to Qena University Hospital to be further evaluated by a qualified neurologist and for further investigations, such as neuroimaging and electroencephalography.nnnRESULTSnOne hundred patients had a confirmed diagnosis of epilepsy, with a lifetime prevalence of 12.46/1000. The active prevalence rate of epilepsy was 2.12/1000, while the incidence rate was 123/100000. Seventy-six percent of the patients had idiopathic epilepsies, while 24% had symptomatic epilepsy. Generalized epilepsies were more common (70.1%) than partial epilepsy (26.3%), meanwhile epilepsies with mixed seizure types were 2.6%. The most common seizure type was generalized tonic clonic seizures (51.8%). The age-specific prevalence rate of epilepsy was much higher in infancy and early childhood (62.5 and 37.04/1000, respectively), which regressed steadily with age. Idiopathic epilepsies were significantly more common in urban areas than in rural areas (P=0.01), while symptomatic epilepsies were more common in rural areas than in urban areas (P<0.005).nnnCONCLUSIONnUpper Egypt is characterized by a relatively high incidence and prevalence of epilepsy and epilepsy-related medical service, and more cultural education should be directed to those areas in Egypt.

Prevalence of Parkinsonism and Parkinson's disease in Qena governorate/Egypt: a cross-sectional community-based survey

Abstract Background and purpose: In a previous study we found a high crude prevalence rate (CPR) for Parkinsons disease (PD) in Assiut governorate/Egypt. We therefore surveyed a second Nile valley governorate (Qena) to provide confirmatory evidence for the high prevalence rate of PD in Egypt. Subjects and methods: 10 areas in Qena governorate were selected by random sampling to recruit 8027 inhabitants. Positive cases were identified using a modified screening questionnaire, the unified Parkinson disease rating scale (UPDRS), mini-mental state examination (MMSE) and the non-motor symptoms scale (NMSS) for PD. Results: Forty-four patients were identified with Parkinsonism, giving a CPR of 548/105 inhabitants. Among them, 35 patients were diagnosed as PD with CPR of 436/105; three cases were diagnosed as drug-induced Parkinsonism with CPR 37/105; two cases had atherosclerotic Parkinsonism with CPR 25/105.Age-specific CPR of PD among population aged ≥u200950u200ayears old was 2534/105.The highest age-specific CPR was recorded among subjects ≥u200975u200ayears old. The CPR showed a tendency to be higher in males than females, urban than rural areas and industrial than non-industrial areas (503 vs 363/105, 474 vs 389/105 and 655 vs 312/105, respectively). There was a significantly higher CPR among illiterate than literate persons (1982 vs 299/105 with Pu2009=u20090.00001). About one quarter of patients had cognitive impairment. All cases had positive symptoms in at least one or more NMS Domains. Conclusion: The overall prevalence of PD disease is high in Nile valley governorates of Upper Egypt compared to other Arabic countries.

Prevalence of Bell's palsy in Qena Governorate, Egypt.

Background and purpose: There have been few studies to estimate the prevalence of Bell’s palsy (BP) in Arab countries. A community-based study was conducted to estimate the prevalence, incidence rates, precipitating factors, and outcome of BP in Qena Governorate, Egypt. Subjects and methods: A door-to-door survey was carried out, with random sampling of 10 districts, involving 9303 inhabitants, 51.1% males and 48.9% females. Seventeen subjects were positive in screening questionnaire and referred to Qena University hospital and were subjected to a full clinical examination, House Brackmann’s Facial grading system. Results: In a total population of 9303 individuals, 15 cases were confirmed as having BP giving a prevalence rate (PR) 161/105 for all ages 95%CI (80–243). It was slightly but not significantly higher among women and the rural community. The incidence rate of BP was 107/105. The highest age-specific rate was 40–49 years age. The most frequent precipitating factors for an episode of BP were exposure to air draft in 40%, physical stress (13.3%), and upper respiratory tract infection (13.3%). Moreover, 46.7% had predisposing risk factors, DM and hypertension in 33.3%. Sixty percent of cases had complication and poor outcome. Conclusion: The overall prevalence and incidence rates of BP in Qena governorate were high. This could be related to the variation in day and night temperature in our community and the susceptibility to air draft exposure during the night. The high frequency of poor outcome among studied cases suggests that better local guidelines should be implemented to recognize and treat BP.

Prevalence of Common Types of Compression Neuropathies in Qena Governorate/Egypt: A Population-Based Survey

Background: No epidemiological studies on the prevalence of compressive neuropathy have been undertaken in Arab countries. The aim of the study was to estimate the prevalence of the most common types of compressive neuropathies in Qena governorate/Egypt. Methods: The study was part of a community-based survey carried out to assess the prevalence of neuromuscular disorders among the Qena population. A random sampling of 10 districts, 5,039 inhabitants aged ≥20. There were 3,050 urban residents (60.5%) and 1,989 (39.5%) from the rural community. Patients were diagnosed using a screening questionnaire for diagnosis of entrapment neuropathies. Positive cases were referred to the Qena University Hospital. They were given full clinical, electrophysiological and laboratory investigations. Results: Compressive neuropathy was recorded in 165 cases giving a CPR = 3.3% of population at risk (≥20 years). Carpal tunnel syndrome (CTS) was diagnosed in 155 cases giving a CPR = 3.1% with a significantly higher prevalence among females than males (5.3 vs. 0.9%) and in rural compared with urban populations (4.6 vs. 2.1%). Ulnar neuropathy at the elbow was the second common type of entrapment with a CPR = 0.1% followed by radial nerve palsy, tarsal tunnel syndrome and common peroneal nerve palsy. Conclusion: The overall crude prevalence rate of CTS is comparable with that in other countries.