Faculty Bibliography

Objective: To examine whether a history of childhood adversity (i.e. abuse, dysfunction) influence clinical features of multiple sclerosis (MS) in adult patients. maltreatment, and household Background: Multiple epidemiological studies have linked adverse childhood experiences to changes in brain structure and stress-responsive physiologic mechanisms. Such changes have been found to profoundly increase risk for chronic disease, poorer emotional and social functioning, and cognitive impairment in adulthood. However, the specific role of these experiences in MS remains unclear. Design/Methods: Participants with MS were recruited from a cohort that previously completed a larger cognitive remediation trial. Measures included the Adverse Childhood Experience (ACE) and Resilience Questionnaire (RQ) self-report inventories. ACE and RQ scores were compiled into a composite score to provide a more comprehensive measure of endured childhood adversity, and these measures were compared to individual disease features. Results: A total of 76 participants completed the study (mean age 49.8+/-12.5 and 80% female). ACE scores were significantly and inversely correlated with RQ scores (r = -0.46, p<0.001), suggesting that greater childhood adversity corresponds with poorer psychological resilience. ACE, but not RQ, significantly predicted age of onset (r= -0.31, p=0.03 and r= -1.91, p=0.18 respectively). Both ACE and RQ were linked to estimated premorbid cognitive functioning (r= -0.30, p=0.009 and r= -0.27, p=0.02). However, the composite score of both measures offered the strongest predictive value for the impact of childhood adversity on age of onset (r= -0.31, p=0.02) and premorbid cognitive functioning (r = -0.32, p=0.005). Neither ACE nor RQ were related to age, current disability, or current level of cognitive impairment measured by the Symbol Digit Modalities Test (SDMT). Conclusions: Cumulative stress due to adverse childhood experiences and decreased psychological resilience may increase the likelihood of earlier MS onset and predict poorer premorbid cognitive functioning in adulthood

Cognitive impairment affects more than half of all individuals living with multiple sclerosis (MS). We hypothesized that training at home with an adaptive online cognitive training program would have greater cognitive benefit than ordinary computer games in cognitively-impaired adults with MS. This was a double-blind, randomized, active-placebo-controlled trial. Participants with MS were recruited through Stony Brook Medicine and randomly assigned to either the adaptive cognitive remediation (ACR) program or active control of ordinary computer games for 60 hours over 12 weeks. Training was remotely-supervised and delivered through a study-provided laptop computer. A computer generated, blocked stratification table prepared by statistician provided the randomization schedule and condition was assigned by a study technician. The primary outcome, administered by study psychometrician, was measured by change in a neuropsychological composite measure from baseline to study end. An intent-to-treat analysis was employed and missing primary outcome values were imputed via Markov Chain Monte Carlo method. Participants in the ACR (n = 74) vs. active control (n = 61) training program had significantly greater improvement in the primary outcome of cognitive functioning (mean change in composite z score+/-SD: 0.25+/-0.45 vs. 0.09+/-0.37, p = 0.03, estimated difference = 0.16 with 95% CI: 0.02-0.30), despite greater training time in the active control condition (mean+/-SD:56.9 +/- 34.6 vs. 37.7 +/-23 .8 hours played, p = 0.006). This study provides Class I evidence that adaptive, computer-based cognitive remediation accessed from home can improve cognitive functioning in MS. This telerehabilitation approach allowed for rapid recruitment and high compliance, and can be readily applied to other neurological conditions associated with cognitive dysfunction. TRIAL REGISTRATION: Clinicaltrials.gov NCT02141386.

BACKGROUND: Adverse childhood experiences (ACEs) exert a psychological and physiological toll that increases risk of chronic conditions, poorer social functioning, and cognitive impairment in adulthood. OBJECTIVE: To investigate the relationship between childhood adversity and clinical disease features in multiple sclerosis (MS). METHODS: Sixty-seven participants with MS completed the ACE assessment and neuropsychological assessments as part of a larger clinical trial of cognitive remediation. RESULTS: Adverse childhood experience scores, a measure of exposure to adverse events in childhood, significantly predicted age of MS onset (r = -0.30, p = 0.04). ACEs were also linked to reading recognition (a proxy for premorbid IQ) (r = -0.25, p = 0.04). ACE scores were not related to age, current disability, or current level of cognitive impairment measured by the Symbol Digit Modalities Test (SDMT). CONCLUSION: Childhood adversity may increase the likelihood of earlier age of onset and poorer estimated premorbid IQ in MS.

Neuropsychologists regularly conduct sport-related concussion (SRC) evaluations, although research has not tracked these assessment practices. As part of a survey of neuropsychological test usage, we analyzed data from 215 neuropsychologists who conduct SRC evaluations. Only 15% reported conducting baseline assessments of athletes as part of a sports program and 92% evaluate athletes' post-concussion without baseline data. The majority of respondents use a full battery, considered the most reliable approach for assessing concussion symptoms in athletes. Only 6% use computerized tests exclusively (>50% ImPACT). We discuss the implications of these results and address challenges faced by neuropsychologists who perform SRC evaluations.

OBJECTIVES: Transcranial direct current stimulation (tDCS) has potential clinical application for symptomatic management in multiple sclerosis (MS). Repeated sessions are necessary in order to adequately evaluate a therapeutic effect. However, it is not feasible for many individuals with MS to visit clinic for treatment on a daily basis, and clinic delivery is also associated with substantial cost. We developed a research protocol to remotely supervise self- or proxy-administration for home delivery of tDCS using specially designed equipment and a telemedicine platform. MATERIALS AND METHODS: We targeted ten treatment sessions across two weeks. Twenty participants (n = 20) diagnosed with MS (any subtype), ages 30 to 69 years with a range of disability (Expanded Disability Status Scale or EDSS scores of 1.0 to 8.0) were enrolled to test the feasibility of the remotely supervised protocol. RESULTS: Protocol adherence exceeded what has been observed in studies with clinic-based treatment delivery, with all but one participant (95%) completing at least eight of the ten sessions. Across a total of 192 supervised treatment sessions, no session required discontinuation and no adverse events were reported. The most common side effects were itching/tingling at the electrode site. CONCLUSIONS: This remotely supervised tDCS protocol provides a method for safe and reliable delivery of tDCS for clinical studies in MS and expands patient access to tDCS.

Research Objectives: Examine gender differences in self-reported postconcussion symptoms among individuals referred for neuropsychological services. Research has shown female gender is associated with increased susceptibility to emotional, physiological, sensory, and cognitive symptom clusters (King, 2014). Few studies have demonstrated which symptom cluster females are more likely to endorse. This study evaluates gender differences in symptomatology subsequent to various causes of concussion as research has shown this has implications for outcomes. Design: Retrospective study of adult concussion patients. Setting: Outpatient concussion center in an urban medical center. Participants: 100 patients (female = 59; mean age = 40.69 years) diagnosed with concussion or Post-Concussion Syndrome (PCS). Falls (33%), motor vehicle injuries (24%), and struck by an object (21%) were the top causes of injury. Interventions: Neuropsychological or psychological assessment. Main Outcome Measure(s): Sport Concussion Assessment Tool (SCAT 3). Results: Results indicated female concussion patients endorsed more physiological and sensory symptoms including nausea/vomiting (t(85.83)=-2.02, p <.05), dizziness (t(91) = -2.17, p <.05), balance problems (t(85.94) = -2.33, p <.05), sensitivity to light (t(91) = -3.18, p <.01 ), and sensitivity to noise (t(91) = -2.30, p <.05) than males. Additionally, females reported experiencing higher total numbers of symptoms (t(54.45)=-2.03, p <.05) and symptom severity (t(91) = -2.29, p <.05 ) than males. No gender differences were found with regard to cognitive, emotional, and sleep symptoms. Conclusions: A gender effect was demonstrated on several physiological and sensory concussion symptoms suggesting females to be more symptomatic than males. Results are consistent with previous findings indicating female athletes reported increased somatic symptoms postconcussion than male athletes. These findings can provide insight for rehabilitation specialists to develop more gender-specific approaches for treating female non-sport concussion patients