Effects of non-invasive brain stimulation in multiple sclerosis: systematic review and meta-analysis

The effectiveness of non-invasive brain stimulation in treatment of major depressive disorder (MDD): a systematic review and transfer analysis

This study aimed to analyze the transferability of non-invasive brain stimulation (NIBS) interventions in individuals with major depressive disorder (MDD) based on the FIELD model (Function, Implementation, Ecology, Level, and Duration), encompassing function, implement, ecology, level, and duration. A systematic search of electronic databases yielded a total of 21 eligible studies, comprising 12 transcranial direct current stimulation (tDCS) and 9 transcranial magnetic stimulation (TMS) trials, involving 1029 individuals with MDD. The meta-analysis of effect sizes revealed positive transfer effects across all domains of the FIELD model, suggesting that NIBS interventions have potential efficacy in improving various facets of MDD. The subgroup analysis highlighted that bilateral dlPFC stimulation exhibited the highest effect size for transferability, indicating greater transferability for rTMS, a higher dose of stimulation, and the integration of additional interventions. Additionally, the study discusses the implications of bilateral dorsolateral prefrontal cortex (dlPFC) stimulation and the integration of complementary therapies for optimizing treatment efficacy.

Transcranial direct current stimulation for cognitive rehabilitation in people with multiple sclerosis: A systematic review of randomized controlled trials

People with multiple sclerosis (PwMS) often experience cognitive impairments that affect independence in their activities. Transcranial direct current stimulation (tDCS) has been recently used for treating cognitive impairments in patients with neurological conditions. This review aims to investigate the effects of tDCS on cognitive function in PwMS. Databases including "PubMed, SCOPUS, MEDLINE, EMBASEe, and Web of Science" were searched until July 2024. The risk of bias was evaluated using the Cochrane Collaboration tool (CCT). Nine were selected for inclusion in this review, encompassing 274 PwMS, 77.74% of whom were females. Five studies have a low risk of bias, while four have a moderate risk of bias on the CCT. The findings revealed mixed evidence regarding the effects of tDCS on cognitive function in PwMS. In conclusion, most studies have shown that tDCS does not improve various cognitive domains in PwMS. However, due to the limited number of studies and their high heterogeneity, further research is needed to assess the immediate and long-term impacts of tDCS on numerous cognitive domains in PwMS, understand the relationship between PwMS characteristics and their response to the tDCS intervention, and define the optimal tDCS treatment protocols for treating cognitive impairments in PwMS.

Home-based transcranial direct current stimulation paired with cognitive training to reduce fatigue in multiple sclerosis

Fatigue is a common and often debilitating feature of multiple sclerosis (MS) that lacks reliably effective treatment options for most patients. Transcranial direct current stimulation (tDCS), a safe and well-tolerated type of noninvasive brain stimulation, is a low-cost and home-based approach with the potential to reduce fatigue in MS. We conducted a double-blind, sham-controlled, randomized clinical trial to compare active vs. low-dose (sham) tDCS paired with computer-based cognitive training, delivered as a home-based intervention, to reduce MS-related fatigue. Participants with MS-related fatigue, but without depression, were stratified by neurologic disability using the Extended Disability Status Scale (EDSS) and randomized to complete 30 daily sessions over six weeks of either active or sham tDCS paired with online cognitive training (BrainHQ). The primary outcome was the change in PROMIS Fatigue score from baseline to the end of the intervention. A total of 117 participants were randomized, with 92% completing all treatment sessions. Both groups showed significant reductions in fatigue, with no significant difference between them. This suggests that tDCS does not provide any additional benefit over cognitive training alone in reducing fatigue, but confirms the feasibility and tolerance of this home-based intervention.

Enhancing the effect of rehabilitation on multiple sclerosis: A randomized clinical trial investigating the impact of remotely-supervised transcranial direct current stimulation and virtual reality telerehabilitation training

BACKGROUND

Multiple sclerosis (MS) is a demyelinating disease characterized by balance and gait impairment, fatigue, anxiety, depression, and diminished quality of life. Transcranial direct current stimulation (tDCS) has emerged as an effective intervention for managing these symptoms.

OBJECTIVE

This study aims to investigate the efficacy of remotely supervised tDCS (RS-tDCS) applied to the left dorsolateral prefrontal cortex, in conjunction with a telerehabilitation (TR) program, on motor (balance and gait), cognitive (executive functions), and participation outcomes (fatigue, anxiety, depression, and quality of life) in persons with MS (pwMS).

METHODS

In this multicenter interventional randomized controlled trial, pwMS were randomly assigned to: TR with active tDCS (TR RS-AtDCS, n = 20) or TR with sham tDCS (TR RS-StDCS, n = 21). Two additional groups of historical controls were represented by comparable TR (TR, n = 35) or usual care (UC, n = 35). The TR RS-tDCS program comprised a 6 weeks of rehabilitation intervention delivered through a hybrid mix model TR, five sessions a week each lasting 45 min with additional 20 min of tDCS during the first week.

RESULTS

The subjects underwent to TR treatments (TR; TR RS-AtDCS; TR RS-StDCS) exhibited post-treatment improvements compared to UC group in Mini-BESTest global score (p = 0.013, T0 vs T1 ̶ UC group: p = 0.429, TR groups: p < 0.001), anterior postural control (p = 0.028, T0 vs T1 ̶ UC group: p = 0.860, TR groups: p < 0.001), and dynamic walking (p = 0.010, T0 vs T1 ̶ UC group: p = 0.269, TR groups: p = 0.012). The TR RS-AtDCS group showed improvement in the 12-item MSWS (p = 0.006) and STAI-Y (p = 0.032) compared to UC, TR and TR RS-StDCS.

CONCLUSIONS

This study underscores the benefits of TR in addressing motor challenges (balance and gait) among pwMS. The incorporation of RS-tDCS positively impacted on participants' perceived walking difficulties and reduced anxiety. The novelty of this study lies in its comprehensive evaluation of motor, quality of life, and emotional outcomes within home-based interventions. These findings highlight the potential of combined interventions to enhance well-being in pwMS.

An update on the treatment and management of cognitive dysfunction in patients with multiple sclerosis

INTRODUCTION

Cognitive impairment (CI) occurs in 34-70% of multiple sclerosis (MS) patients, significantly impacting quality of life. CI can occur independently of physical disability, even in those with 'benign MS.' Cognitive deficits are heterogeneous, but common areas affected include processing speed, memory, and executive functions.

AREAS COVERED

A comprehensive literature search was conducted across databases such as PubMed and Google Scholar, using keywords like 'MS,' 'cognition,' and 'cognitive rehabilitation.' We focused on clinical assessment tools, emerging cognitive phenotypes, and both pharmacological and non-pharmacological treatments, including disease-modifying therapies and cognitive rehabilitation techniques.

EXPERT OPINION

Current evidence underscores the need for a multifaceted approach to managing CI in MS, incorporating emerging pharmacological treatments, cognitive rehabilitation strategies, and exercise programs. Future research should prioritize defining optimal training intensities, integrating therapies for sustained cognitive enhancement, and exploring neuromodulation and neuroimaging biomarkers within randomized controlled trials aimed at improving cognitive functioning in MS.

Evidence-Based Umbrella Review of Non-Invasive Neuromodulation in Chronic Neuropathic Pain

BACKGROUND AND OBJECTIVE

Non-invasive neuromodulation techniques (NIN), such as transcranial Direct Current Stimulation (tDCS) and repetitive Transcranial Magnetic Stimulation (rTMS), have been extensively researched for their potential to alleviate pain by reversing neuroplastic changes associated with neuropathic pain (NP), a prevalent and complex condition. However, treating NP remains challenging due to the numerous variables involved, such as different techniques, dosages and aetiologies. It is necessary to provide insights for clinicians and public healthcare managers to support clinical decision-making. This umbrella review aims to consolidate existing evidence on the effectiveness of various NIN in managing chronic NP.

DATABASES AND DATA TREATMENT

A systematic search was conducted in the PubMed/MEDLINE database, including meta-analyses of controlled trials comparing NIN techniques with sham interventions for NP treatment. The quality of included studies was assessed using the AMSTAR-2 tool and the GRADE system, with effect sizes adjusted to the standard mean difference (SMD).

RESULTS

The review included 22 meta-analyses comprising 8151 participants from 214 controlled trials. The most investigated NIN techniques were tDCS and rTMS, with primary targets being the motor cortex and dorsolateral prefrontal cortex. The findings suggest that excitatory protocols, particularly high-frequency rTMS and anodal tDCS, are effective in reducing pain intensity in individuals with NP. However, the overall quality of evidence was rated low, primarily due to heterogeneity among studies and small sample sizes.

CONCLUSION

NIN techniques show promise in managing NP, with potential benefits in pain reduction. However, further high-quality research is needed to establish optimal protocols and long-term effects.

SIGNIFICANCE STATEMENT

This paper consolidates the evidence regarding non-invasive neuromodulation for the treatment of neuropathic pain, including differentiating the most effective techniques based on the aetiology of pain, and provides clinicians with easy access to this critical information. It also highlights key aspects that require further research in the field of non-invasive neuromodulation and neuropathic pain.

The Potential of Transcranial Direct Current Stimulation (tDCS) in Improving Quality of Life in Patients with Multiple Sclerosis: A Review and Discussion of Mechanisms of Action

Background/Objectives: Multiple sclerosis (MS) is the most prevalent incurable nontraumatic neurological disability in young individuals. It causes numerous symptoms, including tingling, fatigue, muscle spasms, cognitive deficits, and neuropsychiatric disorders. This disease significantly worsens quality of life (QoL), and this dimension of general functioning provides valuable information about the effectiveness of treatment and well-being. There are psychological interventions that can improve QoL, but their number is limited. Therefore, searching for new methods that are as effective and safe as possible is ongoing. Methods: This review examines the potential effectiveness of transcranial direct current stimulation (tDCS) in improving the quality of life in patients with MS. Searches were conducted in the PubMed/Medline, Research Gate, and Cochrane databases. Results: The search yielded seven studies in which QoL was a primary or secondary outcome. Stimulation protocols displayed heterogeneity, especially concerning the choice of the stimulation site. Four studies demonstrated the effectiveness of tDCS in improving QoL, all of which (two) used anodal stimulation of the left DLPFC. Stimulation of the motor cortex has produced mixed results. The potential mechanisms of action of tDCS in improving QoL in MS are explained. These include improved synaptic plasticity, increased cerebral blood flow, salience network engagement through tDCS, and reduction of beta-amyloid deposition. The limitations are also detailed, and recommendations for future research are made. Conclusions: While the evidence is limited, tDCS has shown potential to improve QoL in MS patients in some studies. Prefrontal stimulation appears promising, and further research is recommended to explore this approach.

Non-invasive brain stimulation enhances the effect of physiotherapy for balance and mobility impairment in people with Multiple Sclerosis

BACKGROUND

Impairment of balance and gait is common in Multiple Sclerosis (MS). Non-invasive Brain Stimulation techniques are promising adjuncts to physical therapy to improve disability.

OBJECTIVE

To determine if combining transcranial direct current stimulation (tDCS) with conventional exercise therapy enhances balance and mobility in people with multiple sclerosis (PwMS) compared to exercise alone.

METHODS

In a double-blind randomised controlled trial, PwMS were randomised into a real or sham tDCS group. All patients received individualized exercise treatment. Twelve sessions of real (intensity 2mA, bipolar) or sham tDCS was administered over the primary motor area for 20 minutes followed by one hour of physiotherapy focusing on balance, strength, and mobility, twice a week for six weeks. Outcome measures included balance (Berg Balance Score), mobility (10m Walk Test), fatigue (Fatigue Severity Scale) and quality of life (Multiple Sclerosis Quality of Life - 54) performed 1 week before intervention, at week 7 (1-week post-intervention), and at six months post-intervention. Falls questionnaire was completed 1 week before intervention and at 6 months post-intervention. Generalised linear mixed model analysis was used to compare outcomes at different time points within groups (before and after exercise treatment) and between groups (sham vs real stimulation groups).

RESULTS

Forty participants (mean age 54 and mean EDSS 3.5) were randomly allocated to receive real (n=19) or sham (n=21) stimulation, with 36 completing the post-intervention (real 17, sham 19) and 32 completing the 6-month assessments (real 15, sham 17). All participants had significantly improved balance and mobility scores post exercise treatment (within groups comparison, p<0.05). Between groups comparison found a small but significant improvement in the Berg Balance Score (mean improvement 1.9 and 2 points, p <0.05) and 10-metre Walk Test (mean improvement of 0.09 and 0.11m/s, p <0.05) in the real tDCS group compared to the sham group after six weeks of training and at six months follow-up, respectively. There was no benefit in fatigue, falls and QOL scores in the real stimulation group compared to the control group.

CONCLUSION

Our results suggest that the addition of tDCS prior to exercise treatment provides a significant improvement in walking speed and balance in people with MS which lasts longer, compared to exercise alone. Further study is needed to optimize the use of this relatively inexpensive and well tolerated device for rehabilitation.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trial Registry (ACTRN12628001836224).

Can non-motor outcomes be improved in chronic stroke? A systematic review on the potential role of non-invasive brain stimulation

BACKGROUND

Non-invasive brain stimulation induces changes in spontaneous neural activity in the cerebral cortex through facilitatory or inhibitory mechanisms, relying on neuromodulation of neural excitability to impact brain plasticity. This systematic review assesses the state-of-the art and existing evidence regarding the effectiveness of NIBS in cognitive recovery among patients with chronic stroke.

MATERIALS AND METHODS

We conducted a systematic search, following PRISMA guidelines, for articles published from January 2010 through September 2023. We searched the following databases: PubMed, Embase, Cochrane Database of Systematic Reviews, PEDro, Rehab Data, and Web of Science.

RESULTS

Our electronic searches identified 109 papers. We assessed and included 61 studies based on their pertinence and relevance to the topic. After reading the full text of the selected publications and applying predefined inclusion criteria, we excluded 32 articles, leaving 28 articles for our qualitative analysis. We categorized our results into two sections as follows: (1) Cognitive and emotional domains (11 studies), (2) language and speech functions (16 studies).

CONCLUSION

Our findings highlight the potential of NIBS, such as tDCS and rTMS, in the cognitive, linguistic, and emotional recovery of post-stroke patients. Although it seems that NIBS may work as a complementary tool to enhance cognitive and communication abilities in patients with stroke -also in the chronic phase- evidence on behavioural outcomes is still poor. Future studies should focus on this important issue to confirm the effectiveness of neuromodulation in chronic neurological diseases. PROSPERO Registration: CRD42023458370.

Brain stimulation for patients with multiple sclerosis: an umbrella review of therapeutic efficacy

Multiple sclerosis patients often experience various symptoms that can greatly impact their quality of life. There are various brain stimulation techniques that have been evaluated for their ability to reduce the symptoms of multiple sclerosis. However, there is inconsistency in the specific stimulation methods used and the symptoms targeted in the existing research. This umbrella review conducted in order to evaluate the effectiveness of brain stimulation and identify limitations and gaps for further research. In this umbrella review, we conducted a searched on Web of Knowledge, PubMed, and Scopus database. We specifically looked for reviews, with or without meta-analyses, that have investigated the effects of brain stimulation methods on symptoms of multiple sclerosis. All articles were examined by AMSTAR 2 (A Measure Tool to Assess Systematic Review 2). We identified 155 articles, of which 14 were eligible for inclusion. Of those, five were qualitative studies and nine were meta-analyses. Among the included studies, four examined the use of deep brain stimulation, while ten investigated the therapeutic potential of noninvasive brain stimulation. Considering the heterogeneity of studies, the current evidence suggests that repetitive transcranial magnetic stimulation may be effective in treating pain and improving motor function, while transcranial direct current stimulation may be useful in alleviating fatigue and enhancing certain aspects of cognitive performance. Deep brain stimulation, on the other hand, appears to be effective in reducing tremors. However, further research is warranted to validate these findings and address the existing limitations in the field.

Noninvasive brain stimulation for spasticity rehabilitation in multiple sclerosis: A systematic review of randomized controlled trials

OBJECTIVE

To investigate the effects of noninvasive brain stimulation (NIBS) on spasticity in people with multiple sclerosis (PwMS).

LITERATURE SURVEY

We searched PubMed, SCOPUS, MEDLINE, REHABDATA, PEDro, CINAHL, AMED, and Web of Science until December 2022.

METHODOLOGY

Studies were selected if they included PwMS, used transcranial direct current stimulation (tDCS) or repetitive transcranial magnetic stimulation (rTMS) as a main intervention, and were randomized controlled trials (RCTs) including at least one outcome measure evaluating spasticity. Two researchers individually screened the selected studies. The study's quality was assessed using the Cochrane Collaborations tool. The researchers decided that the meta-analysis was not possible because the treatment interventions varied among the selected studies.

SYNTHESIS

In total, 147 studies were reviewed. Of them, nine studies met the eligibility criteria and included 193 PwMS (mean age = 43.2 years), 54.4% of whom were female. Eight studies were considered "high" quality and one was considered "moderate" quality. Seven studies that used rTMS demonstrated a significant decrease in spasticity in PwMS after the intervention. The remaining studies that provided tDCS did not show meaningful effects.

CONCLUSIONS

The evidence for the influences of rTMS on spasticity in PwMS is promising. The evidence for the impact of tDCS on spasticity in PwMS was limited. Further RCTs with long-term follow-ups are encouraged.

Transcranial direct current stimulation (tDCS) in the treatment of neuropsychiatric symptoms of long COVID

The study aimed to assess the efficacy of transcranial direct current stimulation (tDCS) in the treatment of neuropsychiatric (NP) symptoms of the post-acute sequelae of SARS-CoV-2 infection (PASC), known as the long COVID. A double-blind, randomized, sham-controlled study compared the efficacy and safety of prefrontal cortex active tDCS to sham-tDCS in treating NP-PASC. Patients diagnosed with NP-PASC, with a Fatigue Impact Scale (FIS) score ≥ 40, were eligible for the study. Twenty tDCS sessions were administered within four weeks, with continuous, end-of-treatment, and follow-up measurements. The primary outcome was a change in the FIS at the end-of-treatment, analyzed in the intention-to-treat population. Data from 33 patients assigned to active (n = 16) or sham-tDCS (n = 17) were analyzed. After the treatment, a decrease in the FIS score was more pronounced in the sham than in the active group, yet the intergroup difference was insignificant (11.7 [95% CI -11.1 to 34.5], p = 0.6). Furthermore, no significant intergroup differences were observed regarding anxiety, depression, quality of life, and cognitive performance. The small cohort sample, differences in baseline FIS scores between groups (non-stratified randomization), or chosen stimulation parameters may have influenced our findings. However, it might also be possible that the expected mechanism of action of tDCS is insufficient to treat these conditions.

Does non-invasive brain stimulation improve spatiotemporal gait parameters in people with multiple sclerosis? A systematic review and meta-analysis

BACKGROUND

Multiple sclerosis (MS) is a chronic autoimmune disease that causes progressive functional impairment, mainly in walking tasks. Noninvasive brain stimulation (NIBS) could influence the motor function and improving gait ability of patients.

OBJECTIVE

The aim was to analyze the effects of NIBS (transcranial direct current stimulation [tDCS] or transcranial magnetic stimulation [TMS] on functional locomotion in people with multiple sclerosis (PwMS).

METHODS

A search was conducted for randomized controlled trials published up to November 2023 comparing the application of NIBS versus a sham or control group. The primary outcome were spatiotemporal gait parameters and functional mobility. Two review authors independently assessed the risk of bias in the included studies, and we used the Grading of Recommendations Assessment, Development, and Evaluation methodology to rate the certainty of the evidence for each outcome. A meta-analysis was performed by pooling the appropriate data using RevMan Web.

RESULTS

A total of four clinical trials were included for metanalysis. We observed that there is no statistically significant difference in overall effect in gait speed (MD = 0.08; 95% CI: -0.08-0.24; p = 0.32), and cadence (MD = 0.22; 95% CI: -11.54-11.98; p = 0.97%) between groups. But there was a statistically significant difference in overall effect in stride length between groups (MD:0.19; 95% CI: 0.07-0.31; p = 0.002), mainly when the intervention performed by multiple sessions and associated with motor rehabilitation (MD = 0.29; 95% CI: 0.14-0.44; p = 0.0002).

CONCLUSIONS

tDCS applied by multiple session and combined with motor rehabilitation (i.e., aerobic and/or resistance training) can improve stride length in PwMS.

The Cortical Silent Period and Its Association with Fatigue in Multiple Sclerosis: The Need for Standardized Data Collection

The cortical silent period (CSP), assessed with transcranial magnetic stimulation (TMS), provides insights into motor cortex excitability. Alterations in the CSP have been observed in multiple sclerosis (MS), although a comparison of the sometimes contradictory results is difficult due to methodological differences. The aim of this study is to provide a more profound neurophysiological understanding of fatigue's pathophysiology and its relationship to the CSP. Twenty-three patients with MS, along with a matched control group, underwent comprehensive CSP measurements at four intensities (125, 150, 175, and 200% resting motor threshold), while their fatigue levels were assessed using the Fatigue Scale for Motor and Cognitive Functions (FSMC) and its motor and cognitive subscore. MS patients exhibited a significantly increased CSP duration compared to controls (p = 0.02), but CSP duration was not associated with the total FSMC, or the motor or cognitive subscore. Our data suggest a systematic difference in MS patients compared to healthy controls in the CSP but no association with fatigue when measured with the FSMC. Based on these results, and considering the heterogeneous literature in the field, our study highlights the need for a more standardized approach to neurophysiological data collection and validation. This standardization is crucial for exploring the link between TMS and clinical impairments in diseases like MS.

Post-stroke fatigue: a review of development, prevalence, predisposing factors, measurements, and treatments

Background

Post-stroke fatigue (PSF) is a ubiquitous and overwhelming symptom for most stroke survivors. However, there are no effective management strategies for PSF, which is partly due to our limited understanding.

Objective

In this paper, we review the development, prevalence, predisposing factors, measurements, and treatments of PSF.

Results

PSF is an independent symptom after stroke, with a prevalence ranging from 42 to 53%, which depends on the selection of measurement tools and stroke characteristics. It is affected by biological, physical, and psychological factors, among which inflammation may play a key role.

Conclusion

Numerous but non-specific evaluation measurement tools limit the management of PSF. In clinical practice, it may be beneficial to identify PSF by combining scales and objective indexes, such as walking tests and electromyographic examinations. There are no evidence-based interventions to improve PSF. However, increasing evidence suggests that transcranial direct-current stimulation and mindfulness-based interventions may become promising treatments. Further studies are urgently needed to better understand the etiology of PSF, thereby providing the basis for developing new measurement tools and targeted treatments.

Effectiveness of transcranial direct current stimulation on balance and gait in patients with multiple sclerosis: systematic review and meta-analysis of randomized clinical trials

BACKGROUND

Motor impairments are very common in neurological diseases such as multiple sclerosis. Noninvasive brain stimulation could influence the motor function of patients.

OBJECTIVE

The aim of this meta-analysis was to evaluate the effectiveness of transcranial direct current stimulation (tDCS) on balance and gait ability in patients with multiple sclerosis. Additionally, a secondary aim was to compare the influence of the stimulation location of tDCS on current effectiveness.

METHODS

A search was conducted for randomized controlled trials published up to May 2023 comparing the application of tDCS versus a sham or control group. The primary outcome variables were balance and gait ability.

RESULTS

Eleven studies were included in the qualitative analysis, and ten were included in the quantitative analysis, which included 230 patients with multiple sclerosis. The average effect of tDCS on gait functionality was superior to that of the control group (SMD = -0.71; 95% CI, -1.05 to -0.37). However, the overall results of the tDCS vs. sham effect on static balance did not show significant differences between groups (MD = 1.26, 95% CI, -1.31 to 3.82). No significant differences were found when different locations of tDCS were compared.

CONCLUSIONS

These results reveal that tDCS is an effective treatment for improving gait ability with a low quality of evidence. However, the application of tDCS has no effect on static balance in patients with multiple sclerosis with very low quality of evidence. Similarly, there seems to be no difference regarding the stimulation area with tDCS.

Chronic Functional Adaptations Induced by the Application of Transcranial Direct Current Stimulation Combined with Exercise Programs: A Systematic Review of Randomized Controlled Trials

The present systematic review aimed to determine the chronic effects of the combination of transcranial direct current stimulation (tDCS) and exercise on motor function and performance outcomes. We performed a systematic literature review in the databases MEDLINE and Web of Science. Only randomized control trials that measured the chronic effect of combining exercise (comprising gross motor tasks) with tDCS during at least five sessions and measured any type of motor function or performance outcome were included. A total of 22 interventions met the inclusion criteria. Only outcomes related to motor function or performance were collected. Studies were divided into three groups: (a) healthy population (n = 4), (b) neurological disorder population (n = 14), and (c) musculoskeletal disorder population (n = 4). The studies exhibited considerable variability in terms of tDCS protocols, exercise programs, and outcome measures. Chronic use of tDCS in combination with strength training does not enhance motor function in healthy adults. In neurological disorders, the results suggest no additive effect if the exercise program includes the movements pretending to be improved (i.e., tested). However, although evidence is scarce, tDCS may enhance exercise-induced adaptations in musculoskeletal conditions characterized by pain as a limiting factor of motor function.

Cognitive impairment and its treatment in patients with multiple sclerosis

Cognitive impairment (CI) is a relatively common manifestation of multiple sclerosis (MS), which can occur with any type of the disease course and activity. The largest CI prevalence and severity are observed in progressive MS. In relapsing-remitting MS the most prominent deterioration of cognitive functions is seen during relapses; however, in some patients it can continue also throughout remission. In a small number of patients CI can be the most significant symptom of the disease; in addition, it sometimes can be the only clinical feature of the relapse. Despite this, in clinical practice CI remains out of the focus of attention, and is not evaluated when assessing the disease severity and/or activity, while CI is not included into EDSS. Nonetheless, a number of specialized neuropsychological tests and batteries has been developed recently, which can be used for both screening and detailed assessment of CI in MS, as well as for assessment of its changes over time. CI has a negative impact on MS patients' quality of life, their social interactions, daily and occupational activities. The influence of disease-modifying agents on CI has been poorly investigated; however, there is evidence that they can reduce the degree of CI. The optimal choice of pathogenetic treatment in patients with CI remains understudied. There is no convincing evidence of the effectiveness of symptomatic pharmacological treatment of CI in MS, and cognitive rehabilitation is the only approach with confirmed effectiveness. Considering the limitations of this technique (its availability, quite a big number of sessions), there is a need to search for other methods to increase its efficacy, including non-invasive neuromodulation (in particular, transcranial direct current stimulation or transcranial magnetic stimulation). This article is focused on a brief review of the main diagnostic methods of CI in MS, its pathogenetic and symptomatic treatment, and cognitive rehabilitation techniques, as well as on the results of the studies on non-invasive neuromodulation.

Neuronal activity and NIBS in developmental myelination and remyelination - current state of knowledge

Oligodendrocytes are responsible for myelinating central nervous system (CNS) axons. and rapid electrical transmission through saltatory conduction of action potentials. Myelination and myelin repair rely partially on oligodendrogenesis, which comprises. oligodendrocyte precursor cell (OPC) migration, maturation, and differentiation into. oligodendrocytes (OL). In multiple sclerosis (MS), demyelination occurs due to an. inflammatory cascade with auto-reactive T-cells. When oligodendrogenesis fails, remyelination becomes aberrant and conduction impairments are no longer restored. Although current disease modifying therapies have achieved results in modulating the. faulty immune response, disease progression continues because of chronic. inflammation, neurodegeneration, and failure of remyelination. Therapies have been. tried to promote remyelination. Modulation of neuronal activity seems to be a very. promising strategy in preclinical studies. Additionally, studies in people with MS. (pwMS) have shown symptom improvement following non-invasive brain stimulation. (NIBS) techniques. The aforementioned mechanisms are yet unknown and probably. involve both the activation of neurons and glial cells. Noting neuronal activity. contributes to myelin plasticity and that NIBS modulates neuronal activity; we argue. that NIBS is a promising research horizon for demyelinating diseases. We review the. hypothesized pathways through which NIBS may affect both neuronal activity in the. CNS and how the resulting activity can affect oligodendrogenesis and myelination.

Transcranial direct current stimulation for post-COVID fatigue: a randomized, double-blind, controlled pilot study

Fatigue is one of the most frequent and disabling symptoms of the post-COVID syndrome. In this study, we aimed to assess the effects of transcranial direct current stimulation on fatigue severity in a group of patients with post-COVID syndrome and chronic fatigue. We conducted a double-blind, parallel-group, sham-controlled study to evaluate the short-term effects of anodal transcranial direct current stimulation (2 mA, 20 min/day) on the left dorsolateral prefrontal cortex. The modified fatigue impact scale score was used as the primary endpoint. Secondary endpoints included cognition (Stroop test), depressive symptoms (Beck depression inventory) and quality of life (EuroQol-5D). Patients received eight sessions of transcranial direct current stimulation and were evaluated at baseline, immediately after the last session, and one month later. Forty-seven patients were enrolled (23 in the active treatment group and 24 in the sham treatment group); the mean age was 45.66 ± 9.49 years, and 37 (78.72%) were women. The mean progression time since the acute infection was 20.68 ± 6.34 months. Active transcranial direct current stimulation was associated with a statistically significant improvement in physical fatigue at the end of treatment and 1 month as compared with sham stimulation. No significant effect was detected for cognitive fatigue. In terms of secondary outcomes, active transcranial direct current stimulation was associated with an improvement in depressive symptoms at the end of treatment. The treatment had no effects on the quality of life. All the adverse events reported were mild and transient, with no differences between the active stimulation and sham stimulation groups. In conclusion, our results suggest that transcranial direct current stimulation on the dorsolateral prefrontal cortex may improve physical fatigue. Further studies are needed to confirm these findings and optimize stimulation protocols.

A review of current rehabilitation practices and their benefits in patients with multiple sclerosis

Multiple sclerosis (MS) is a chronic, debilitating disease characterised by demyelination of the nerves of the central nervous system that results in patients progressively losing the ability to perform daily tasks. As there is no cure for this disease, rehabilitation therapy is an important aspect of care; assisting patients to regain or retain function and improve their physical, mental and social wellbeing. At present there is no current consistent model of care for MS, likely due to the variable symptom presentation. Various forms of rehabilitation therapy are available, and these include physical rehabilitation methods, such as balance and gait therapy, speech and respiration rehabilitation, and occupational therapy. Contrary to previous understanding, exercise-based therapies have shown various benefits for patients with MS, and in addition to improving MS-related physical symptoms, have been shown to reduce the risk of developing cardiovascular disease and can improve cognitive function. Cognition rehabilitation therapy specifically focuses on behavioural tasks and is divided into two main forms: compensatory rehabilitation, which offers cognitive functioning benefits, and restorative rehabilitation, which offers memory benefits. Excitation therapies include cranial stimulation and other stimulation rehabilitation methods such as focal muscle vibration therapy and these non-invasive techniques may improve patient's physical ability. Additionally, more novel rehabilitation methods include robot-assisted gait therapy and telerehabilitation, both of which are expected to play progressively more prominent roles in the future of rehabilitation therapy. The structure of the care team has been found to impact patient outcomes, and both in- and out-patient care settings have been found to be beneficial, dependant on the patient's circumstances, with certain patients better suited to a particular setting. While a single point of care is recommended for patients, a multidisciplinary care team and regular reassessment is recommended to manage changing symptoms and ensure continuity of care. The importance of the critical components of rehabilitation have been identified, and these are of vital importance in achieving beneficial outcomes. These components include the patients' participation in the treatment, goal setting with a multidisciplinary care team, a guiding-light purpose for the patient, which focusses on recognizing their personal potential and obtaining improvements through a tailored plan. The final critical component of rehabilitation is the results measurement, which highlights the need for a quantifiable reduction in impairment and improvement in activity and participation. Overall, a lack of standardisation in outcome measurements makes comparison challenging. This is particularly important when comparing standard methods of care with more novel rehabilitation techniques. However, within the broad area of rehabilitation therapies, it is clear that patients with MS can benefit from rehabilitation practices; physically, mentally and socially.

Symptom burden, management and treatment goals of people with MS spasticity: Results from SEEN-MSS, a large-scale, self-reported survey

BACKGROUND

Spasticity occurs frequently in people with multiple sclerosis (PwMS) and may affect non-physical aspects of life. However, there is a paucity of data assessing the full impact of spasticity in PwMS.

OBJECTIVE

This survey of PwMS and spasticity (PwMSS) was undertaken to understand the impact of spasticity in physical, functional, emotional, and social domains.

METHODS

SEEN-MSS (Symptoms and Emotions Exploration Needed in Multiple Sclerosis Spasticity), an online survey, was developed in collaboration with three US-based MS organizations (conducted February-April 2021).

RESULTS

Survey was completed by 1,177 PwMSS, 78% female, mean age 56.8yrs, 16.8yrs from MS diagnosis, 11.5yrs with spasticity. Considering day-to-day goals of treatment, respondents reported that managing symptoms(46%) was nearly as important as slowing disease progression(54%). Most reported spasticity was a constant reminder of their MS. Participants reported that spasticity limited daily activities (92%), caused pain (92%), impaired sleep (89%) and negatively impacted emotional well-being (87%). Spasticity fostered a sense of dependence (61%), isolation (40%), decline in self-confidence (75%), self-image (70%), and social connection (62%).

CONCLUSIONS

Spasticity has wide-reaching negative impacts on multiple aspects of life, causing substantial burden for PwMSS. Results emphasize the need to fully understand the burden of spasticity and addressing individual needs of PwMSS.

The effectiveness of anodal tDCS and cognitive training on cognitive functions in multiple sclerosis; a randomized, double-blind, parallel-group study

BACKGROUND

Forty to 70% of patients with multiple sclerosis (MS) suffer from cognitive impairment during their illness. Only a few studies have examined the effects of anodal transcranial direct current stimulation (a-tDCS) along with cognitive training on cognitive performance in MS patients. This study aims to determine whether multi-session a-tDCS with or without cognitive training impacts cognitive performance in MS.

METHODS

Eighty MS patients received a-tDCS, cognitive training, a-tDCS plus cognitive training, and sham for ten consecutive daily sessions. Cognitive function (including episodic memory, attention, and inhibitory control, working memory, and visuospatial skill) was measured at baseline, week 4, and week 12 after the intervention.

RESULTS

All cognitive functions significantly improved after the intervention compared to the sham condition. This effect also showed persistence during follow-up for some cognitive tasks in the a-tDCS and a-tDCS combined cognitive training groups. Although the cognitive training group experienced an immediate improvement in attention and inhibitory control, the difference was not significant at follow-up. Also, there were no significant differences between these three groups in cognitive scores after the intervention.

CONCLUSION

a-tDCS alone and a-tDCS paired with or without cognitive training as compared to sham appears to be a promising therapeutic option for cognitive performance in MS patients.

Non-invasive brain stimulation therapy on neurological symptoms in patients with multiple sclerosis: A network meta analysis

OBJECTIVE

The aim of the study was to evaluate non-invasive brain stimulation (NIBS) [including transcranial magnetic stimulation (TMS) and transcranial electrical stimulation (tES)] on neurological symptoms in patients with multiple sclerosis (PwMS).

METHOD

We searched PubMed, Embase, Cochrane Library, Web of Science and Ovid MEDLINE until February 2022. And we evaluated the included studies for methodological quality by the Cochrane bias risk assessment tool and assessed the studies' certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We performed network meta analysis (NMA) by using Stata 15 and ranked the results of the NMA by using the surface under the cumulative ranking curve (SUCRA) ranking chart.

RESULT

Twenty seven clinical trials were finally included (N = 596, 66.4% women). For the immediate effects, rTMS over M1 yielded the most optimal scheme for fatigue reduction among all the interventions compared to the sham stimulation groups [MD = -0.85, 95% CI (-1.57, -0.14)] (SUCRA = 82.6%). iTBS over M1 yielded the most signifcant reduced pain level than the sham groups did [MD = -1.26, 95% CI (-2.40, -0.11)] (SUCRA = 98.4%). tDCS over F3 was the best protocol of NIBS to improve quality of life (QOL) [MD = 1.41, 95% CI = (0.45,2.36)] (SUCRA = 76.7%), and iTBS over M1 may significantly reduce spasticity compared to sham stimulation [MD = -1.20, 95% CI = (-1.99, -0.41)] (SUCRA = 90.3%). Furthermore, rTMS, tRNS, and tDCS on certain areas may improve PwMS accuracy, response time, manual dexterity, pain relief and QOL, but does not show statistically significant differences. The evidence assessed using GRADE is very low.

CONCLUSION

Based on the NMA and SUCRA ranking, we can conclude that symptoms including fatigue, pain, spasticity, and QOL can be improved by following NIBS protocol after treatment. Nonetheless, most of the included studies lack a good methodology, and more high-quality randomized clinical trials are needed.

The effectiveness and safety of repetitive transcranial magnetic stimulation on spasticity after upper motor neuron injury: A systematic review and meta-analysis

To systematically evaluate the effectiveness and safety of repetitive transcranial magnetic stimulation (rTMS) on spasticity after upper motor neuron (UMN) injury. Eight electronic databases were searched from inception to August 6, 2022. Randomized controlled trials (RCTs) investigating the effectiveness and safety of rTMS on spasticity after UMN injury were retrieved. Two reviewers independently screened studies, extracted data, and assessed the risk of bias. Review Manager 5.3 and Stata 14.0 software were used to synthesize data. The certainty of the evidence was appraised with the Grade of Recommendation, Assessment, Development and Evaluation tool. Forty-two studies with a total of 2,108 patients were included. The results of meta-analysis revealed that, compared with control group, rTMS could significantly decrease scores of the Modified Ashworth Scale (MAS) in patients with UMN injury. The subgroup analysis discovered that rTMS effectively decreased the MAS scores in patients with stroke. Meanwhile, rTMS treatment > 10 sessions has better effect and rTMS could decrease the MAS scores of upper limb. Thirty-three patients complained of twitching facial muscles, headache and dizziness, etc. In summary, rTMS could be recommended as an effective and safe therapy to relieve spasticity in patients with UMN injury. However, due to high heterogeneity and limited RCTs, this conclusion should be treated with caution.

Repetitive Transcranial Magnetic Stimulation of the Primary Motor Cortex beyond Motor Rehabilitation: A Review of the Current Evidence

Transcranial magnetic stimulation (TMS) has emerged as a novel technique to stimulate the human brain through the scalp. Over the years, identifying the optimal brain region and stimulation parameters has been a subject of debate in the literature on therapeutic uses of repetitive TMS (rTMS). Nevertheless, the primary motor cortex (M1) has been a conventional target for rTMS to treat motor symptoms, such as hemiplegia and spasticity, as it controls the voluntary movement of the body. However, with an expanding knowledge base of the M1 cortical and subcortical connections, M1-rTMS has shown a therapeutic efficacy that goes beyond the conventional motor rehabilitation to involve pain, headache, fatigue, dysphagia, speech and voice impairments, sleep disorders, cognitive dysfunction, disorders of consciousness, anxiety, depression, and bladder dysfunction. In this review, we summarize the latest evidence on using M1-rTMS to treat non-motor symptoms of diverse etiologies and discuss the potential mechanistic rationale behind the management of each of these symptoms.

The Big Five Personality Traits and Positive Orientation in Polish Adults with Multiple Sclerosis: The Role of Meaning in Life

Scientific achievements concerning the direct relation between personality traits and positive orientation among patients with multiple sclerosis do not explain the role of potential mediators. In fact, some researchers argue that the traits–positivity association is much more complex than it seems to be. For this reason, we made an attempt to analyze the indirect relationship between the above-mentioned variables, including meaning in life as a mediator. In total, 618 patients with MS took part in the study. The NEO Five-Factor Inventory, the Positive Orientation Scale, and the Meaning in Life Questionnaire were used. The results showed that positive orientation/the presence of meaning/searching for meaning correlated positively with extraversion, openness to experience, agreeableness, and conscientiousness, and were negatively associated with neuroticism. Moreover, meaning in life in both its dimensions acted as a mediator in 9 of 10 models. It can be assumed that a propensity to establish interpersonal relationships (extraversion), use active imagination (openness), inspire confidence among others (agreeableness), and take responsibility (conscientiousness) can have an impact on someone’s positive attitude toward oneself and the surrounding world (positive orientation) when people have meaning in life and when they are seeking it.