Faculty Bibliography

INTRODUCTION/BACKGROUND:To demonstrate the broad utility of the remotely supervised transcranial direct current stimulation (RS-tDCS) protocol developed to deliver at-home rehabilitation for individuals with multiple sclerosis (MS). METHODS:Stimulation delivered with the RS-tDCS protocol and paired with adaptive cognitive training was delivered to three different study groups of MS patients to determine the feasibility and tolerability of the protocol. The three studies each used consecutively increasing amounts of stimulation amperage (1.5, 2.0, and 2.5 mA, respectively) and session numbers (10, 20, and 40 sessions, respectively). RESULTS:High feasibility and tolerability of the stimulation were observed for n = 99 participants across three tDCS pilot studies. CONCLUSIONS:RS-tDCS is feasible and tolerable for MS participants. The RS-tDCS protocol can be used to reach those in locations without clinic access and be paired with training or rehabilitation in locations away from the clinic. This protocol could be used to deliver tDCS paired with training or rehabilitation activities remotely to service members and veterans.

There has been considerable public interest in the topic of traumatic brain injury (TBI) as a risk factor for development of late-life dementia. A review was performed on empirical studies examining the relationship between these two conditions. Although results from a number of studies clearly demonstrate that TBI is a positive risk factor for developing dementia, there are an equivalent number of studies that obtain inconclusive or negative findings. Inconsistencies across studies are often the result of methodological findings including the nature of the investigational design, choice of comparison groups, and criteria used to define cases. In many studies, the diagnosis of TBI is obtained retrospectively in a manner that is subject to bias. Accurate identification of dementia cases is often compromised by the use of inappropriately brief follow-up periods and variations in diagnostic methods. There remains no universally accepted neurobiological mechanism to explain the transition from acute TBI to the chronic effects of dementia. Studies of specialty populations, including athletes and military personnel are beset by secular and cohort effects, raising questions about the applicability of findings to the general population. No existing studies have been able to exclude the possible effects of confounding medical or lifestyle factors in facilitating the onset of dementia following TBI. Although the research findings suggest a general association between TBI and dementia, the specifics of the relationship remain poorly defined.

Pediatric multiple sclerosis (MS) is an increasingly recognized rare subgroup of patients presenting with a unique set of diagnostic challenges. Understanding the early development of MS may offer a window into the pathogenesis of disease; however further research is needed, particularly within the field of genetics and to understand the complex environmental and biological interactions at work. Acute disseminated encephalomyelitis (ADEM) remains a hallmark presentation of early pediatric disease and can be a monophasic illness or end up being reclassified as a relapsing disorder. The clinical expression is shaped in part by the prepubertal or postpubertal state of the patient. Other syndromes can also present with ADEM, and a specific differential diagnosis exists for children presenting with any initial demyelinating event (IDE). New definitions and criteria have allowed early detection of MS. However applying adult criteria to very young children should be approached with caution. There is now a major effort in studying disease-modifying therapy (DMT) in children due to requirements from regulatory authorities. Pediatric patients respond well to therapy and often do best with an interdisciplinary approach focusing on social aspects, cognition, and fatigue which enhances the achievement of successful outcomes.
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This paper describes ten core features of a neuropsychological assessment with the aim of helping neurologists understand the unique contribution the evaluation can make within the wider context of diagnostic methods in epilepsy. The possibilities, limitations and cautions associated with the investigation are discussed under the headings below: 1. A neuropsychological assessment is a collaborative investigation. 2. Assessment prior to treatment allows for the accurate assessment of treatment effects. 3. The nature of an underlying lesion and its neurodevelopmental context play an important role in shaping the associated neuropsychological deficit. 4. Cognitive and behavioural impairments result from the essential comorbidities of epilepsy which can be considered as much a disorder of cognition and behaviour as of seizures. 5. Patient's subjective complaints can help us understand objective cognitive impairments and their underlying neuroanatomy, resulting in improved patient care. At other times, patient complaints reflect other factors and require careful interpretation. 6. The results from a neuropsychological assessment can be used to maximise the educational and occupational potentials of people with epilepsy. 7. Not all patients are able to engage with a neuropsychological assessment. 8. There are limitations in assessments conducted in a second language with tests that have been standardized on different populations to that of the patient. 9. Adequate intervals between assessments maximise sensitivity to meaningful change. 10. Patients should be fully informed about the purpose of the assessment and have realistic expectations of the outcome prior to referral.

Introduction: Cognitive impairment in pediatric onset multiple sclerosis (POMS) occurs in up to one third of cases.
Objective(s): To screen for cognitive impairment early in the disease course of POMS, measure predictive factors, and determine the effect of relapse on cognitive processing speed.
Aim(s): To identify cognitive processing speed impairment among POMS and pediatric clinically isolated (CIS) patients enrolled in the US Pediatric MS and Other Demyelinating Disease Registry. In March 2014, the Symbol Digit Modalities Test (SDMT) scores were analyzed from March 2014, when the SDMT was added to the clinical evaluation through July 2018, when the data set was locked.
Method(s): SDMT raw scores were converted to age-normative z-scores using validated age and sex adjusted means. Processing speed impairment was defined with z-score increments of-1.0. Clinically meaningful decline in longitudinal analyses was defined by a z-score decrease of 1.0 or more.
Result(s): For the POMS (n=500) and CIS (n=116) with at least one SDMT, the mean age at symptom onset was 13.5 years and the mean (+SD) disease duration at the initial SDMT assessment was 3.0 + 2.9 years. A total of 23.4% of MS and 16.4% of CIS patients had impaired processing speed at initial assessment. SDMT impairment was predicted by worse EDSS, longer disease duration, and lower level of mother's educational achievement. On longitudinal follow-up (n=383, mean follow-up: 1.8 years), 14.1% had clinically meaningful decline predicted by older age of MS onset, male gender, and longer test-retest interval. Disease relapse and steroid use were associated with transient SDMT worsening.
Conclusion(s): Early in the disease course, a subgroup of POMS patients are at risk for cognitive impairment and subsequent decline. Screening for cognitive slowing is critical for prompt identification of potential cognitive deficits and initiation of additional services