Role of transcranial direct current stimulation on reduction of postsurgical opioid consumption and pain in total knee arthroplasty: Double randomized clinical trial.

BACKGROUND: Postoperative pain control is an important factor in determining recovery in total knee arthroplasty (TKA).The aim of the study was to assess the efficacy of 4 sessions of transcranial direct current stimulation (tDCS) over primary motor cortex (M1) in patients undergoing unilateral TKA. MATERIALS: Fifty patients undergoing TKA were included in the study. They were divided randomly into two groups (25 patients for each, using closed envelopes): real tDCS (2 mA, 20 min, with anodal stimulation applied over M1 postoperative for 4 consecutive days) and sham tDCS. Opioid consumption was titrated by an anaesthesiologist during the study period and was used as primary outcome. As a secondary outcome, patients were evaluated using Visual Analogue Scale (VAS) and Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale (LANSS) at baseline, then the 1st, 2nd, 3rd and 4th days after operation. RESULTS: There was no significant difference between real and sham tDCS in any rating scales at baseline. The opioid consumption and LANSS scores decreased more in patients who received real tDCS over the course of the treatment than sham tDCS. Real tDCS was associated with 59% reduction in the titrated analgesia. There was no significant difference between groups (time × groups interaction) in the VAS. CONCLUSION: Since the VAS was constant, repeated sessions of anodal tDCS over M1 with an extra-cephalic cathodal electrode can achieve the same degree of analgesia with less opioid consumption over the postoperative days after TKA. Thus, tDCS is a promising tool in the field of postoperative analgesia. SIGNIFICANCE: The data of the present study suggest that four sessions of transcranial direct current brain stimulation over motor cortex could reduce morphine consumption and pain perception during the postoperative period in total knee arthroplasty.

Transcranial magnetic stimulation identifies cortical excitability changes in monosymptomatic nocturnal enuresis.

OBJECTIVES: A limited number of electroencephalography (EEG) studies in nocturnal enuresis (NE) have reported cortical dysmaturity. The aim of the present study was to test this notion by examining cortical excitability in subjects with nocturnal enuresis (NE) using transcranial magnetic stimulation (TMS). MATERIAL AND METHODS: We investigated 41 patients with NE meeting the DSM-IV diagnostic criteria for NE, and 18 age- and sex-matched controls. Each subject was assessed clinically regarding frequency, duration of enuresis and Health Survey Measurement. Neurophysiological measures included resting and active motor thresholds (RMT, AMT), motor evoked potentials (MEP) of upper and lower limbs, cortical silent period duration (CSP) and transcallosal inhibition (TCI), in the upper limbs. RESULTS: Patients had a significantly lower Health Survey Measurement score for both physical and mental health components compared to the control group. RMT and AMT of both upper and lower limbs as well as the duration of the CSP and TCI were significantly reduced compared with the control group. There was significant positive correlation between RMT, AMT and Health Survey Measurement scores, especially Social Functioning. CONCLUSION: Patients with nocturnal enuresis are characterized by pathologically increased excitability and reduced inhibitory processing in the motor cortex, which could contribute to the pathogenesis of nocturnal enuresis.

Repetitive transcranial magnetic stimulation in neuropathic pain secondary to malignancy: a randomized clinical trial.

BACKGROUND: Significant analgesic effects of repetitive transcranial magnetic stimulation (rTMS) have been found in several studies of patients with chronic pain of various origins, but never for malignancy. The objective of this study was to assess the efficacy of 10 sessions of rTMS over the primary motor cortex (M1) in patients suffering from malignant neuropathic pain. METHODS: Thirty-four patients were randomly allocated into one of two groups to receive real (20 Hz, 10 s, 10 trains with 80% intensity) or sham rTMS daily for 10 consecutive days. Patients were evaluated using a verbal descriptor scale (VDS), a visual analogue scale (VAS), Leeds assessment of neuropathic symptoms and signs (LANSS) and Hamilton rating scale for depression (HAM-D) at baseline, after the first, fifth and 10th treatment sessions, and then 15 days and 1 month after treatment. RESULTS: There were no significant differences between real and sham groups in the duration of illness or pain rating scores at the baseline. A significant 'Time × Group' interaction was recorded indicating that real and sham rTMS had different effects on the VDS, VAS, LANSS and HAM-D scales. Post-hoc testing showed that the group of patients treated with real rTMS had greater improvement in all scales that persisted up to 15 days, but were not present 1 month later. Significant positive correlations between the percentage of pain reduction and HAM-D after the 10th session and 15 days later were recorded. CONCLUSION: The results demonstrate that 10 rTMS sessions over the M1 can induce short-term pain relief in malignant neuropathic pain.

Altered cortical excitability in anorexia nervosa.

OBJECTIVES: Recent EEG and positron emission tomography (PET) studies have reported hyperactivation of the right hemisphere in anorexia nervosa (AN). The aim of the present study was to test this notion by examining cortical excitability in subjects with AN using transcranial magnetic stimulation (TMS). METHODS: We investigated thirteen patients meeting the DSM IV diagnostic criteria for AN and 14 controls age and sex matched. Each subject was assessed clinically using the Eating Disorder Inventory (EDI), the Eating Attitude Test (EAT) and Beck's Depression Inventory (BDI-II). TMS measures involved resting and active motor thresholds (RMT, AMT) as well as motor evoked potentials (MEP), cortical silent period duration (CSP), transcallosal inhibition (TCI), and short latency intracortical inhibition (SICI) of the first dorsal interosseous muscle (FDI) were assessed. Cortical esophageal MEP latencies (CL) were also recorded. RESULTS: The RMT and MEP onset latency of the FDI and the esophagus as well as duration of the TCI were significantly reduced in anorexic patients compared to the control group. There were no significant differences neither in AMT nor CSP between patients and controls. Moreover, we found significant negative correlations between the EAT scores and RMT, and TCI duration. Although anorexic patients had significantly higher BDI score, there was no correlation between it and cortical excitability. CONCLUSION: Anorexic individuals are characterized by pathologically increased motor and esophageal cortical excitability that significantly correlates with clinical symptoms of anorexia nervosa.

Therapeutic effects of peripheral magnetic stimulation on traumatic brachial plexopathy: clinical and neurophysiological study.

OBJECTIVE: To evaluate the therapeutic effects of peripheral repetitive magnetic stimulation (rMS) on recovery of traumatic brachial plexopathy. PATIENTS AND METHODS: Thirty-four patients with traumatic brachial plexopathy were studied. Strength of different muscles of upper limbs was evaluated neurologically. Nerve conduction studies (NCS), upper limb F-waves and visual analogue scales (VAS) for shoulder pain were obtained for all patients. These were randomly assigned into two groups with a ratio of 2:1; each patient received conventional physical therapy modalities and active exercises as well as real or sham rMS applied over the superior trapezius muscle of the affected limb daily for 10 sessions. Patients were reassessed with the same parameters after the 5th and the 10th session, and 1 month after rMS treatment. RESULTS: No significant between-group differences were recorded at baseline assessment. Significant improvement was observed (time X groups) after real rMS in comparison to the sham group (P=0.0001 for muscle strength and 0.01 for VAS of shoulder pain). These improvements were still present at 1 month after the end of treatment. In accordance with the clinical improvement, a significant improvement was recorded in the neurophysiological parameters in the real vs the sham group. CONCLUSIONS: We demonstrate that peripheral rMS for 10 sessions may have positive therapeutic effects on motor recovery and pain relief in patients with traumatic brachial plexopathy. Therefore, it is a useful adjuvant in the therapy of these patients.

The relationship between motor cortex excitability and severity of Alzheimer's disease: a transcranial magnetic stimulation study.

INTRODUCTION: In Alzheimer's disease (AD), transcranial magnetic stimulation (TMS) studies have been limited to test motor cortical excitability. The aim of this study was to investigate the inhibitory circuits of the motor cortex and to relate these to measures of cognitive function in AD patients. Results were compared with those of a control group of healthy subjects matched for age, sex and education. PATIENTS AND METHODS: Forty-five AD patients and 37 healthy volunteers were included in the study. Each participant received a neurological evaluation, Mini-Mental State Examination (MMSE), and Clinical Dementia Rating (CDR). Neurophysiological evaluations included resting and active motor threshold (rMT and aMT), motor evoked potential (MEP), cortical silent period (CSP), and transcallosal inhibition (TI). RESULTS: AD patients showed significantly reduced rMT, aMT and shorter MEP onset latency; in addition there was a prolongation of both CSP and TI. There was a significant positive correlation between the MMSE and CDR, on the one hand, and aMT and rMT, on the other hand, whereas the correlation was negative with CSP and TI durations. CONCLUSION: AD is associated with hyperexcitability of the motor cortex, which supports the hypothesis that changes in GABAb and glutamate function are important factors in cognitive impairment.

Cortical excitability of amyotrophic lateral sclerosis: transcranial magnetic stimulation study.

OBJECTIVE: The primary purpose of this study was to provide insight into the central changes that occur in amyotrophic lateral sclerosis (ALS) with a view to understanding how these could contribute to symptoms. MATERIAL AND METHODS: Seventeen patients with definite ALS and 17 control healthy volunteers were included in the study. Clinical examination, amyotrophic lateral sclerosis severity score (ALSSS) and TMS investigations including measurement of resting and active motor threshold (RMT and AMT), motor evoked potential (MEP), input-output curve, contralateral silent period, and transcallosal inhibition (CSP and TI, postulated markers of GABAb function) were measured for each participant. RESULTS: There were no significant differences in RMT or AMT in either hemisphere between patients and the control group. Despite this there was a significant negative correlation between ALSSS and RMT and AMT meaning that increased severity was associated with higher thresholds. MEPs were significantly smaller in ALS patients in comparison to the control group (P = 0.03). There was a significant decrease in the slope of the I/O relationship of MEP amplitude to TMS intensity in patients group in comparison to controls. ALS patients had a significant prolongation of CSP and TI for both hemispheres. There was a tendency for a significant negative correlation between left TI and ALSSS (P = 0.051). CONCLUSION: Measurements of cortical motor excitatory changes in ALS confirm the presence of corticospinal hypoexcitability. Additionally we found increased excitability of presumed intracortical GABAb circuits that correlated with the severity of ALS. We postulate that the disease results in an imbalance between excitation and inhibition in the cortex that can contribute to clinical symptoms.

Contralateral versus ipsilateral rTMS of temporoparietal cortex for the treatment of chronic unilateral tinnitus: comparative study.

BACKGROUND: Repetitive transcranial magnetic stimulation (rTMS) applied over left temporoparietal cortex has been reported to have a long-term therapeutic effect on tinnitus. We compare the impact of 1 and 25 Hz rTMS delivered either contralateral or ipsilateral to symptoms in 62 patients with unilateral chronic tinnitus. MATERIAL AND METHODS: Patients were randomly assigned to one of four treatment groups: with stimulation at 1 or 25 Hz applied either ipsilateral or contralateral to symptoms. Two thousand pulses per session were given daily for 2 weeks. Changes in tinnitus handicap inventory (THI), self-rating scores of loudness, awareness, and annoyance were measured monthly for 10 months. Duration of residual inhibition (RI) and psychiatric morbidity were evaluated monthly for 3 months. RESULTS: There was a significant main effect of time (P < 0.0001) and a significant time x side interaction (P = 0.032) between groups. This was because of the fact that contralateral stimulation had a greater effect on THI than ipsilateral stimulation; it was also superior to left side stimulation (P = 0.027). Ratings of loudness improved more after contralateral rTMS (P = 0.037). Twenty patients had no remaining tinnitus after 3 months; the remainder had a significant increase in RI. Patients with the shortest history of tinnitus tended to respond better to rTMS. There was a significant correlation between changes in THI score and changes in Hamilton anxiety and depression scores. CONCLUSION: Ten daily treatments of 1 and 25 Hz rTMS contralateral to the side of tinnitus have a greater beneficial effect on symptoms than either ipsilateral or left side stimulation.

Long-term effect of repetitive transcranial magnetic stimulation on motor function recovery after acute ischemic stroke.

OBJECTIVE: Although there is evidence for short term benefits of rTMS in stroke, longer term effects have not been reported. The aim of the study was to evaluate the effect of two different frequencies of rTMS on motor recovery and on cortical excitability up to 1 year post-treatment. METHODS: Forty-eight patients with acute ischemic stroke were randomly classified into three groups. The first two groups received real rTMS over motor cortex (3 and 10 Hz respectively) of the affected hemisphere and the third group received sham stimulation of the same site, daily for five consecutive days. Disability was assessed before, after fifth sessions, and then after 1, 2, 3 and 12 months. Cortical excitability was assessed for both hemispheres before and after the second and fifth sessions. RESULTS: A significant 'rTMS x time' interaction was obtained indicating that real and sham rTMS had different effects on rating scales. This was because real rTMS produced greater improvement than sham that was evident even at one year follow-up. These improvements were associated with changes in cortical excitability over the period of treatment. CONCLUSION: These results confirm that real rTMS over motor cortex can enhance and maintain recovery and may be a useful add on therapy in treatment of acute stroke patients.

Role of 1 and 3 Hz repetitive transcranial magnetic stimulation on motor function recovery after acute ischaemic stroke.

BACKGROUND AND PURPOSE: The purpose of this study was to compare the long-term effect of five daily sessions of 1 vs. 3 Hz repetitive transcranial magnetic stimulation (rTMS) on motor recovery in acute stroke. METHODS: A total of 36 patients with acute ischaemic stroke participated in the study. The patients were randomly assigned into one of three groups; the first and second groups received real rTMS; 1 and 3 Hz and third group received sham stimulation, daily for 5 days. Motor disability was assessed before and after the last session, and then after first, second and third month. Cortical excitability was assessed before and after the second and fifth session. The outcome measure was clinical disability at 3 months post-rTMS. RESULTS: No significant differences were found in basal rating scales between the three groups. At the 3-month time point, both of the real rTMS groups had improved significantly more in different rating scales than the sham group; in addition, the 1 Hz group performed better than the 3 Hz group. Measures of cortical excitability immediately after the last session showed that the 1 Hz group had reduced excitability of the non-stroke hemisphere and increased excitability of the stroke hemisphere, whereas the 3 Hz group only showed increased excitability of the stroke hemisphere. CONCLUSION: These results confirm that five daily sessions of rTMS over motor cortex using either 1 Hz over the unaffected hemisphere or 3 Hz over the affected hemisphere can enhance recovery. At 3 months, the improvement was more pronounced in 1 Hz group.

One-year follow up of patients with chronic tinnitus treated with left temporoparietal rTMS.

BACKGROUND AND PURPOSE: Although there are a number of positive reports on the therapeutic effects of repetitive transcranial magnetic stimulation (rTMS) for treatment of tinnitus, there are few details about the duration of treatment effects or the relative efficiency of different rTMS protocols. METHODS: Sixty six patients with chronic tinnitus were divided into four groups, receiving sham rTMS, 1, 10 and 25 Hz rTMS applied each day for 10 days over left temporoparietal cortex. They were followed up at 4 months and 1 year using the tinnitus questionnaire [Tinnitus Handicap Inventory(THI)] and self ratings of annoyance as well as measures of residual inhibition. RESULTS: A two factor anova revealed a significant 'rTMS' x 'time' interaction indicating that real and sham rTMS had different effects on the THI scale and annoyance of tinnitus (P = 0.026 and 0.046 respectively). After 1 year, the tinnitus was absent in one or both ears of 10 patients who had received real rTMS: one of these was in the 1 Hz group, four patients were in the 10 Hz group and five patients were in the 25 Hz group. CONCLUSION: Some patients show a lasting benefit at 1 year after 10 days of rTMS treatment. It appears that treatment at 10 or 25 Hz may be more beneficial than at 1 Hz, although more work is necessary to validate this conclusion.

Treatment of post-stroke dysphagia with repetitive transcranial magnetic stimulation.

BACKGROUND: Up to one-third of patients experience swallowing problems in the period immediately after a stroke. OBJECTIVE: To investigate the therapeutic effect of repetitive transcranial magnetic stimulation (rTMS) on post-stroke dysphagia. MATERIALS AND METHODS: Twenty-six patients with post-stroke dysphagia due to monohemispheric stroke were randomly allocated to receive real (n = 14) or sham (n = 12) rTMS of the affected motor cortex. Each patient received a total of 300 rTMS pulses at an intensity of 120% hand motor threshold for five consecutive days. Clinical ratings of dysphagia and motor disability were assessed before and immediately after the last session and then again after 1 and 2 months. The amplitude of the motor-evoked potential (MEP) evoked by single-pulse TMS was also assessed before and at 1 month in 16 of the patients. RESULTS: There were no significant differences between patients who received real rTMS and the sham group in age, hand grip strength, Barthel Index or degree of dysphagia at the baseline assessment. Real rTMS led to a significantly greater improvement compared with sham in dysphagia and motor disability that was maintained over 2 months of follow-up. This was accompanied by a significant increase in the amplitude of the oesophageal MEP evoked from either the stroke or non-stroke hemisphere. CONCLUSION: rTMS may be a useful adjunct to conventional therapy for dysphagia after stroke.

Dysphagia and hemispheric stroke: a transcranial magnetic study.

INTRODUCTION: Dysphagia is a common and distressing consequence of hemispheric stroke. STUDY AIM: To verify the usefulness of transcranial magnetic stimulation (TMS) studies of swallowing in healthy subjects and in stroke patients. MATERIAL AND METHODS: TMS studies of the motor cortical projections to the upper esophageal sphincter were performed in 45 patients with acute mono-hemispheric stroke (26 patients with dysphagia) and 20 healthy adult volunteers. RESULTS: TMS of either hemisphere in normal volunteers evoked motor evoked potentials (MEP) in the esophagus. The average point of optimal excitability was slightly more anterior in the right hemisphere; otherwise, MEP amplitudes and latencies were similar from both hemispheres as were the areas of the cortical map. The cortical map area and amplitude of MEPs were significantly smaller and the latencies longer after stimulation of the affected hemisphere compared with the unaffected hemisphere and pooled control data. Twenty-four dysphagic patients (92.3%) had abnormalities of MEP of the affected hemisphere, while only five non-dysphagic patients (26%) had these abnormalities. Dysphagic patients were older and had more disability compared with non-dysphagic patients. MEPs of the affected hemisphere of patients with dysphagia were later and smaller in amplitude than MEPs of non-dysphagic patients. The cortical map area was also smaller. CONCLUSION: The esophagus is represented bilaterally in motor cortex, but the hot spot lies more anterior to Cz in right hemisphere compared to left hemisphere. Both the severity of stroke and neuroplasticity of the unaffected hemisphere have implications in the development of dysphagia.

Cortical excitability and transcallosal inhibition in chronic tinnitus: transcranial magnetic study.

INTRODUCTION: It has been proposed that tinnitus may be caused by maladaptive plasticity of processing in the central auditory pathways, and that this may be due in part to a generalised deficit in NMDA-dependent glutamatergic synapses. STUDY AIM: To test this hypothesis, we used transcranial magnetic stimulation to assess the excitability of a number of well-defined synaptic connections in the motor cortex of patients with tinnitus. PATIENTS AND METHODS: Thirty-seven patients with chronic tinnitus and 12 normal age- and sex-matched volunteers were used as a control group. We measured resting and active motor thresholds (rMT/aMT) and the duration of the contralateral and ipsilateral cortical silent periods (CSP and ISP). Short interval intracortical inhibition (SICI) and intracortical facilitation (ICF) were evaluated using a paired pulse stimulation paradigm in the left (dominant) hemisphere. RESULTS: There was no difference between patients and healthy subjects in rMT or aMT or the onset latency of the ISP. The CSP was shorter in patients (P=0.046) whereas the ISP was longer than in healthy subjects (P=0.048) but there was no difference between the hemispheres nor any relation to tinnitus side in patients with predominantly unilateral symptoms. There was no difference in the time course of SICI/ICF between patients and control groups and no significant correlation between tinnitus handicap inventory (THI) score and any of the measures of cortical excitability. CONCLUSIONS: There are small changes incortical excitability in patients with chronic tinnitus. However, given the number of factors we examined in each individual, such minor changes seem unlikely to be an important factor in development of clinical symptoms.

Effect of daily repetitive transcranial magnetic stimulation for treatment of tinnitus: comparison of different stimulus frequencies.

UNLABELLED: We compared the effect of different frequencies of repetitive transcranial magnetic stimulation (rTMS) (1 Hz, 10 Hz, 25 Hz and sham (occipital, 1 Hz)), given daily over the left temporoparietal cortex for 2 weeks, on 66 patients with chronic tinnitus randomly divided into four treatment groups. Patients were assessed using the Tinnitus Handicap Inventory, self-ratings of symptoms and audiometric measures of residual inhibition before, immediately after 2 weeks' treatment and monthly thereafter for 4 consecutive months. RESULTS: There were no significant differences in basal measures between the four groups of patients. A two-factor ANOVA revealed a significant "rTMS" x "time" interaction for all measures. This was because real rTMS produced greater improvement than sham. However, there was no significant difference between the responses to different frequencies of rTMS. The response to rTMS depended on the duration of tinnitus: patients who had tinnitus for the longest period of time were the least likely to respond to treatment. CONCLUSION: Daily sessions of rTMS over the temporoparietal cortex may be a useful potential treatment for tinnitus.

Lack of post-exercise depression of corticospinal excitability in patients with Parkinson's disease.

There is lack of clarity in the literature over whether patients with Parkinson's disease (PD) show the same post-exercise depression of corticospinal excitability as is usually observed in healthy control. This study set out to resolve the problem. Ten patients with idiopathic PD and 10 age-matched controls were included in this study. Each subject performed a submaximal sustained voluntary contraction of the right first dorsal interosseous muscle (FDI) for 10 min or until force could no longer be sustained. Resting motor threshold, motor-evoked potential (MEP), input-output curve, cortical silent period duration, interference pattern (IP) and M/F ratio were recorded at baseline, immediately after fatigue and after 20 min rest. Immediately after exercise, decreased MEP amplitude and increased cortical SP duration were observed in the control group whilst no such changes were observed in PD patients. The input-output curve was also significantly suppressed only in controls, but not in patients. The amplitude of IP was significantly reduced immediately after exercise in both PD patients and controls. Almost all these changes returned nearly to baseline values after 20 min rest. The amount of exercise was approximately equal in both groups because the effect on M-waves and EMG amplitude was similar. However, the expected decline in corticospinal excitability was absent in PD patients. The absence of this effect in PD patients may reflect reorganization of motor commands in response to basal ganglia deficit.

Impaired corticolingual pathways in patients with or without dysarthria after acute monohemispheric stroke.

The occurrence of dysarthria is not infrequent in stroke but little is known about its pathophysiology. The aims of the present study were to assess the central motor innervation of the tongue in normal adults using transcranial magnetic stimulation (TMS) and to compare this with that seen in stroke patients with or without dysarthria. The study included 46 patients with acute monohemispheric stroke due to occlusion of the territory of the middle cerebral artery as documented by CT brain scan (26 patients with dysarthria and 20 patients without dysarthria). Forty-five (age and sex matched) normal volunteers served as controls. Corticolingual pathways were assessed for each subject after TMS of each hemisphere. TMS over the motor cortex of healthy subjects elicited consistent ipsilateral and contralateral lingual responses. The ipsilateral response was usually smaller and approximately 73% of the amplitude of the contralateral response. The cross talk between the two halves of the tongue as estimated after unilateral electrical stimulation of hypoglossal nerve gave a contra/ipsi ratio of 36%, which was significantly smaller than the ratio seen after cortical stimulation (CL). For the patients, with or without dysarthria, motor evoked potential (MEP) latencies (ipsilateral and contralateral) were significantly prolonged after stimulation of affected hemisphere compared with the non-affected hemisphere or the control group (P< 0.001). MEP amplitudes were significantly smaller in hemiplegic patients with dysarthria compared to patients without dysarthria. In patients without dysarthria stimulation of the unaffected hemisphere tended to evoke responses that were of similar size on both sides. There were no significant associations between neurophysiological parameters and side of infarction. We conclude that interruption of the corticolingual pathways is frequent in stroke patients with or without dysarthria. The ability of unaffected hemisphere to evoke responses in the side contralateral to the lesion may relate to the absence or presence of dysarthria.

Longlasting antalgic effects of daily sessions of repetitive transcranial magnetic stimulation in central and peripheral neuropathic pain.

BACKGROUND AND OBJECTIVE: A single session of repetitive transcranial magnetic stimulation (rTMS) over motor cortex had been reported to produce short term relief of some types of chronic pain. The present study investigated whether five consecutive days of rTMS would lead to longer lasting pain relief in unilateral chronic intractable neuropathic pain. PATIENTS AND METHODS: Forty eight patients with therapy resistant chronic unilateral pain syndromes (24 each with trigeminal neuralgia (TGN) and post-stroke pain syndrome (PSP)) participated. Fourteen from each group received 10 minutes real rTMS over the hand area of motor cortex (20 Hz, 10x10 s trains, intensity 80% of motor threshold) every day for five consecutive days. The remaining patients received sham stimulation. Pain was assessed using a visual analogue scale (VAS) and the Leeds assessment of neuropathic symptoms and signs (LANSS) scale, before, after the first, fourth, and fifth sessions, and two weeks after the last session. RESULTS: No significant differences were found in basal pain ratings between patients receiving real- and sham-rTMS. However, a two factor ANOVA revealed a significant "+/- TMS" x "time" interaction indicating that real and sham rTMS had different effects on the VAS and LANSS scales. Post hoc testing showed that in both groups of patients, real-rTMS led to a greater improvement in scales than sham-rTMS, evident even two weeks after the end of the treatment. No patient experienced adverse effects. CONCLUSION: These results confirm that five daily sessions of rTMS over motor cortex can produce longlasting pain relief in patients with TGN or PSP.

Neural maturation of breastfed and formula-fed infants.

BACKGROUND: Human milk provides infants with a full complement of all polyunsaturated fatty acids, including docosahexaenoic acid (DHA) and arachidonic acid (AA). Formula milks only contain the precursors of DHA, AA and linoleic acid, and hence formula-fed infants must synthesize their own DHA and AA. AIM: To evaluate the effect of feeding--whether breastfeeding or formula-feeding--in early infancy upon subsequent neurodevelopment and achievement of optimum brain function. SUBJECTS AND METHODS: The study included 53 normal, healthy infants (30 exclusively breastfed infants and 23 exclusively formula-fed infants) at the age of 1 y (+/-1 mo). Each infant was subjected to a full physical and neurological examination together with neurophysiological studies including flash visual evoked potential (FVEP), brainstem auditory evoked potential (BAEP) and somatosensory evoked potential (SSEP). RESULTS: There was significant prolongation of P100 wave latency of FVEP in formula-fed infants, together with significant prolongation of absolute latency of waves I, III and V of BAEP in formula-fed infants compared with breastfed infants. There was significant prolongation in inter-peak latencies between cortical and Erb's components in formula-fed infants compared with breastfed infants. CONCLUSION: We can conclude that VEP, BAEP and SSEP are more mature in breastfed infants relative to formula-fed infants at 1 y of age, and thus breast milk helps earlier development and maturation of some aspects of the nervous system than milk formulas.

Therapeutic effect of repetitive transcranial magnetic stimulation on motor function in Parkinson's disease patients.

Cortical excitability of the primary motor cortex is altered in patients with Parkinson's disease (PD). Therefore, modulation of cortical excitability by high frequency repetitive transcranial magnetic stimulation (rTMS) of the motor cortex might result in beneficial effects on motor functions in PD. The present study aims to evaluate the effect of rTMS of the motor cortex on motor functions in patients with PD. Thirty-six unmedicated PD patients were included consecutively in this study. The patients were assigned in a randomized pattern to one of two groups, one group receiving real-rTMS (suprathreshold 5-Hz, 2000 pulses once a day for 10 consecutive days) and the second group receiving sham-rTMS using closed envelopes. Total motor section of Unified Parkinson's Disease Rating Scale (UPDRS), walking speed, and self-assessment scale were performed for each patient before rTMS and after the first, fifth, 10th sessions, and then after 1 month. Evaluation of these measures was performed blindly without knowing the type of rTMS. anova for repeated measurements revealed a significant time effect for the total motor UPDRS, walking speed and self-assessment scale during the course of the study in the group of patients receiving real-rTMS (P = 0.0001, 0.001, and 0.002), while no significant changes were observed in the group receiving sham-rTMS except in self-assessment scale (P = 0.019). A 10-day course of real-rTMS resulted in statistically significant long-term improvement of the motor functions in comparison with the sham-rTMS. The rTMS could have a therapeutic role of for PD patients.