Aim: The study aimed to investigate the evaluation and treatment preferences of physiotherapists specializing in neurorehabilitation in Turkey.

Material and Methods: The questionnaire was sent to 546 physiotherapists (PTs), and 94 of them responded (17 %). The average duration of working years was 9.80 ± 9.31. The survey included questions about professional experience and the patient population they treat. It also inquired about the evaluation and treatment methods commonly used by physiotherapists.

Results: The results showed a predominance of stroke survivors (S, 70.21%), followed by Parkinson’s disease (PD, 14.89%) and Multiple Sclerosis (MS, 14.89%). Standardised scales such as Brunnstrom for S, EDSS for MS and Hoehn and Yahr for PD were commonly used for the disease stage. PTs working with S frequently used the Berg balance test or Timed Up and Go (TUG) Test in dynamic balance assessment (31.81%). PTs working with MS prefer TUG or Minibest Test, while PTs working with PD prefer TUG or technology-based assessment for dynamic balance. Task-oriented approaches were preferred for MS (78.6%) and PD (92.9%). The Bobath was preferred for S (92.9%). Virtual reality was preferred for MS (64.3%), robotic systems for S (68.2%) and exergames for PD (42.9%). Postural exercises focusing on balance and coordination were commonly preferred for PD.

Discussion: The findings highlight the importance of standardised assessment tools and treatment guidelines to promote evidence-based practice. Although the low response rate of our study limits the generalizability of the findings, we believe that this study may be a preliminary idea for cross-cultural studies with multiple participants to establish standard evaluations or treatment preferences of PTs in neurorehabilitation.

Keywords: Physiotherapist, Neurorehabilitation, Assessment, Treatment

Introduction

Rehabilitation is an important part of health care. It is applied to many conditions and specific areas [1, 2]. These are to prevent, ameliorate, treat, and protect (World Health Organization, 2030 Action Plan). The primary goal of rehabilitation programmes is to improve the patient’s quality of life and social adjustment by maintaining independence in activities, minimising pain, and disability, and improving the ability to adapt to changing conditions [3]. Neurological problems are one of the most common areas requiring rehabilitation. Millions of people worldwide are affected by neurodegenerative diseases [4]. According to the World Health Organization (WHO), many neurological disorders are chronic and progressive, creating a global and diverse functional problem [5]. Neurological problems have a negative impact on an individual’s health in many ways. To improve the physical and emotional functioning, quality of life and level of social participation of people with neurological conditions, it is necessary to understand the limitations they experience due to neurological conditions [6]. The causes which are genetic disorders, congenital abnormalities or disorders, infections, poor diet, brain injury, spinal cord injury, nerve damage, as well as lifestyle or environmental health issues, can vary from person to person. [7, 8]. Additionally, a neurological problem can also originate in another system that directly or indirectly interacts with the nervous system. For example, Stroke(S) includes brain damage caused by problems in the blood vessels that supply the brain (cardiovascular system); autoimmune disorders involve damage caused by the body’s own immune system [9]. Neurological diseases bring along with them secondary problems and deformities that limit an individual’s independence by negatively affecting the basic components of daily life activities, functionality, productivity, and participation. Problems related to the motor and sensory systems seen in neurological diseases are often accompanied by cognitive, behavioural, sensory, communication, and perceptual disorders [10]. Participation in daily life activities is known to increase individuals’ creativity, improve their skills, and enable them to integrate and adapt to social life [11]. The primary goal of rehabilitation is to determine the limitations that individuals experience due to neurological diseases to improve their quality of life and social participation levels [1]. The most common neurological diseases are S, Multiple Sclerosis (MS), and Parkinson’s Disease (PD). Neurorehabilitation is a process that aims to improve the quality of life by minimizing functional disorders caused by motor and sensory impairments in the nervous system [12]. Successful neurorehabilitation requires a detailed and accurate evaluation process and planning an effective treatment programme [12, 13]. The International Classification of Functioning, Disability and Health (ICF) should be used in the evaluation and preparation of the treatment programme for proper documentation in clinical practice and research projects with a common language. Neurorehabilitation protocols are not like orthopaedic rehabilitation protocols, where the methodology is well established. Treating a variety of neurological conditions with a wide range of symptoms has challenged us to develop unique and individual programmes [14]. However, it may still be a good idea to create a unique protocol with guidelines that include specific assessment and treatment protocols. There is no common perspective on the assessment procedure and treatment methods used in the field of neurorehabilitation in Turkey. The extent of ICF-based assessment and treatment in this area in Turkey, as in the rest of the world, is still unclear. Four-year Physiotherapy and Rehabilitation curriculum (Bachelor of Science) includes neuroanatomy, neurology and neurophysiological approaches and neurological rehabilitation courses. In addition to that, evaluation and treatment methods based on ICF are integrated into neurological rehabilitation and evaluation in undergraduate courses of that curriculum. Physiotherapists (PTs) are trained based on these educational strategies. PTs are fulfilled to work in this field. After graduation, PTs working in neurorehabilitation field may become a member of the Neurological Physiotherapy Working Group, which is a subgroup of the Turkish Physiotherapists Association since the 2000’s.
As far as we know, there are more PTs working in adult neurorehabilitation field in private settings, rehabilitation centres or hospitals than the number of participants of this study. The pragmatic aims of the study were to; (1) find out which assessment tools or evaluation techniques and treatment approaches are most preferred by PTs working in the field of neurorehabilitation in Turkey. (2) To create a common perspective based on PTs’ preferences in this field (3) To establish standards in this field to create guidelines in neurorehabilitation for PTs working in Turkey. With this study, it will be possible to encourage PTs’ working in this field to use and to consider evidence-based neurorehabilitation practice as well.

Material and Methods

Study Design

The present study was a cross-sectional and descriptive design study and was conducted from May 2023 and June 2023. The rights of subjects were protected, and they were asked to sign an informed consent form. This study has been registered on ClinicalTrials.gov with the registration number NCT05855096.
Participants

Ninety-four physiotherapists (64F, 30M) with a mean age of 33.94 ± 9.73 years were included in the study. Inclusion criteria were determined as to have at least 3 years of experience in patient follow-up in neurorehabilitation, to be actively working PTs, to be willingness to participate, and to speak and understand Turkish (for foreign nationals). Participants were excluded from the study if they do not answer or partially answer the sections of the survey (Figure 1. Flowchart of this study).
“Sample Size Calculators” is an online sample size calculation web service that was used to calculate the sample size (https://www.sample-size.net/). The calculations were based on an alpha level of 0.05, a β level of 20%, the expected correlation coefficient is 0.30 and the desired power of 80% [15]. These parameters generate a necessary sample size of at least 85 participants.

Study Protocol

Data collection was carried out using the online survey. The online survey was prepared by researchers with at least ten years of neurorehabilitation clinical practice experience. Before completing and distributing the survey, it was sent to more three PTs who have been working in this field for a long time. The online survey link was delivered via corporate e-mail to PTs. The questionnaire created through Google Forms was delivered to the participants via the link. The link had been active within a month for the data collection process. The participants were informed about the fact that the study was carried out for scientific purposes, and the information was not shared with third parties. Before they started the questionnaire, they were asked whether they were willing to participate. All participants answered “yes” to the question “Do you agree to participate in the survey?”. All participants agree to participate in the survey included in study. The Google Forms questionnaire was sent to the members registered in the Turkish Physiotherapists Association and its neurorehabilitation subgroup members.
A demographic data form was prepared by the researchers and a form prepared via Google Forms to determine evaluation and treatment methods. In the structured questionnaire, we aimed to choose the most preferred assessment tool and evaluation techniques and treatment approaches for their patients suffering from neurological disorders. In addition to this, the physiotherapist’s demographic data, including age, gender, years of experience in the profession, years of experience in the field of neurorehabilitation, and postgraduate education level.

Data Analysis

In this cross-sectional study, descriptive parameters belonging to participants were computed and calculated as mean, standard deviations (mean +SD) and numbers, percentages (% (n)).

Ethical Approval

This study was approved by the Ethics Committee of Biruni University Non-Interventional (Date: 2023-04-17, No:2023/80-12).

Results

The questionnaire was sent to five hundred forty-six PTs working in this field in Turkey. Only 94 physiotherapists met the inclusion criteria in the study. Response rate is 17%. Ninety-four physiotherapists (63F, 31M) with a mean age of 33.84 ± 9.73 years who were included in the study (Figure 1. Flowchart of this study). PTs included in this study have been working for 9.80 ± 9.31 years in neurorehabilitation field. While 59.6 % of PTs have been working at university or university hospitals 20% of them have been working in private hospitals or clinics. 70.21% of them work with S 14.89 % of them work with PD and 14.89 % of them work with MS. While the disease stages were expressed as UPDRS in 29% and Hoehn and Yahr Scale in 71% for PD; it was expressed as 86% EDSS and 14% MSFC for MS patients. PTs working with S prefer to express disease stage as 73% Brunnstrom, 14% Fugl Meyer Assessment (Figure 2). Table 1 and Table 2 represent the assessment preferences of physiotherapists according to findings. Although most of the PTs working with MS and PD prefer to evaluate according to the evidence-based method, only half of PTs working with S prefer to evaluate according to the ease of application. While the Ashworth or Modified Ashworth Scale is the most preferable standardized scale for PTs working with MS and S, PTs working with PD prefer to measure rigidity for muscle tone. PTs working with S (35.7%) stated that using technological based methods for assessing static balance, % 42.85 of them stated that used Timed up and Go Test for dynamic balance. Although PTs working with S (53.03 %) prefer to use observational gait analysis, PTs working with PD prefer to use observational gait analysis (21.42 %), Rivermead mobility index (21.42%) and technological based gait analysis (21.42%). Besides, PTs working with MS (21.42 %) prefer to use the Twelve Item MS Walking Scale (MSWS-12) and observational gait analysis.
PTs working with MS (35.71%) and PTs working with S (62.11 %) preferred to use Functional Independence Measurement (FIM), while half of PTs working with MS preferred to use Barthel Index for Activities of Daily Living (ADL). Most of the PTs working with MS (85.72%), PTs working with PD (71.42%) and PTs working with S (66.69%) prefer to use the Beck Depression Inventory to assess emotional status.
To measure quality-of-life, Multiple Sclerosis Quality of Life-54(MSQOL-54) was preferred by 50 %, the Parkinson’s Disease Quality of Life-39 (PDQ-39) was preferred by the 92.86%, the SF-36 was preferred by PTs working with S by 33.33 %.
PTs working with MS (78.57%) reported using ICF-based assessment in clinical routine, and PTs working with PD (50%) reported using ICF-based assessment for research purposes. However, PTs working with S (34.84%) emphasised using ICF-based assessment both clinically and for research purposes.
The treatment preferences of physiotherapists working in this field are presented in Table 3. Although the 78.6% of PTs working with MS and 92.9% of PTs working with PD prefer to use task-oriented approach, 92.9% of PTs working with S prefer to use Bobath concept PTs working with MS (64.3 %) prefer to use Virtual Reality, PTs working with S (68.2 %) prefer to use robotic systems and PTs working with PD (42.9 %) prefer to use exergames. Although all the PTs working with MS and PD prefer Balance and Coordination exercises, PTs working with S (92.5 %) also prefer Balance and Coordination exercises. All the PTs working with PD prefer to add postural exercises in a treatment program. During treatment programme planning, PTs working with MS (78.6%) and S (39.4%) use ICF in clinical routine, while PTs working with PD (50%) use ICF for research purposes.

Discussion

The results of the study showed that the group of patients encountered by PTs had the highest prevalence of Stroke, followed by Parkinson’s Disease and Multiple Sclerosis. Most of the PTs working in neurorehabilitation field in Turkey prefer and use standardised scales for assessment. For example, Brunnstrom scale for PTs working with S, EDSS for working with MS, Hoehn and Yahr scale for working with PD. Aligning with established clinical practice guidelines, the Berg Balance Test emerged as a widely utilized assessment tool for neurologic conditions, as substantiated by the relevant literature (16). In our study, it was observed that PTs working with S, frequently used the Berg balance test or TUG in the assessment of dynamic balance (31.81%). PTs working with MS prefer TUG or Minibest Test, while physiotherapists working with PD prefer TUG or technology-based assessment for dynamic balance. Only half of the PTs working with S prefer to use observational gait analysis, PTs working with PD prefer to use the Tinetti Gait Scale or observational analysis, and PTs working with MS prefer to use the Twelve Item MS Walking Scale (MSWS-12) or observational gait analysis. There was no consensus on the assessment of dynamic balance and mobility according to the results obtained from our study.
PTs specialising in stroke rehabilitation often prefer to use the FIM as their primary ADL assessment tool because it provides a comprehensive assessment of functional abilities relevant to stroke recovery. For patients with MS, the Barthel Index is often favoured by PTs for its ability to assess functional limitations and guide rehabilitation interventions tailored to the needs of MS patients. The Schwab and England Activities of Daily Living Scale is widely used by PTs working with PD and is recognised for its sensitivity in capturing the unique challenges faced by patients and guiding therapeutic strategies aimed at improving functional independence.
The Beck Depression Inventory appears to be a common scale for all three groups of illnesses to assess emotional status. While PTs working with MS and PD prefer disease-specific assessment scales for the Quality-of-Life scale because it includes more disease-specific conditions, PTs working with stroke prefer the SF-36, which is a general quality of life scale.
Moving beyond assessment tools, the study illuminated distinctive therapeutic approaches employed by PTs based on the nature of the neurological condition. PTs expressed that they prefer to use task-oriented approach for MS and PD, Bobath concept for S survivors. It appears that PTs working with MS and PD are incorporating functional and goal-directed contemporary approaches into their treatment, while those working with S cannot abandon the Bobath concept.
PTs preferred virtual reality and exergames for MS and PD patients respectively and they stated that robotic systems are generally used for S survivors, which may be since mobilisation is more difficult in patients with S. In the related literature, the study about PTs working with S reported that they use Bobath concept for rehabilitation process (17). Balance and coordination exercises are the most preferred type of exercise in neurorehabilitation in our study. A meta-analysis recommended that therapists should implement a regular exercise programme, including aerobic exercise, physical activity, stabilisation exercises, and balance exercises to improve balance for patients with MS, PD, or S (18). Similarly, PTs expressed that aerobic exercise, balance and coordination exercises, strengthening exercises were important when implementing the neurorehabilitation treatment program. The implementation of postural exercises was higher among therapists working with PD than other patient groups. International studies in the literature support our results in the treatment part of the neurorehabilitation field. It has been observed that the ICF perspective in neurorehabilitation is generally used mostly in clinical routine in PTs working with MS, mostly for research purposes in PTs working with PD, and that the use for clinical and research purposes is similar in PTs working with S. However, this study was conducted in Turkey and showed that there are very few standardised tests used for evaluation in the neurorehabilitation field, especially in gait. On the other hand, treatment options preferred by the PTs working in this field are the same as similar studies in the related literature.

Conclusion

In conclusion, the results of our survey suggest that PTs should plan new studies to reach many more PTs working in the neurorehabilitation field. Moreover, PTs would plan cross-cultural studies to compare the findings obtained from the study in the future. We believe that this study could be a preliminary idea for cross-cultural studies with many participants to establish standard assessment or treatment preferences in neurorehabilitation field. Briefly, the study showed that PTs do not actually spend much time on assessment, and the specific equipment facilities in clinics may also negatively influence this condition.

Limitation

The response rate of our study was low because there are very few centres focusing on neurorehabilitation in Turkey. As expected, the number of participants was small in this study. This can be accepted as a limitation of our study.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: None

Conflict of Interest

The authors declare that there is no conflict of interest.

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Güzin Kaya Aytutuldu, Uğur Cavlak, Duygu Kösedağı. Clinical evaluation and treatment preferences of physiotherapists working in neurorehabilitation: A cross-sectional study from Turkey. Ann Clin Anal Med 2024;15(9):609-615

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Aim: This study investigates the neuroprotective, biochemical, and behavioral effects of magnesium L-threonate (MgT) in a rat model of Alzheimer’s disease (AD) induced by aluminum chloride (AlCl3).

Material and Methods: Forty Wistar albino rats were divided into four groups: control (C), Alzheimer’s (AD), positive control (Mg), and protective (Pr). AD was induced by daily intraperitoneal injections of AlCl3 for six weeks. Behavioral assessments were conducted using the head-poking test. Biochemical markers, including Tau protein (Tau), amyloid precursor protein (APP), acetylcholinesterase (AchE), glutathione (GSH), malondialdehyde (MDA), superoxide dismutase (SOD), and albumin, were measured. Histopathological examinations of the hippocampus were also performed.

Results: The AD group exhibited significant behavioral deficits, elevated levels of Tau, APP, AchE, and MDA, and decreased levels of GSH, SOD, and albumin. MgT treatment significantly improved cognitive performance, reduced levels of Tau and APP, and normalized antioxidant enzyme activities. Histopathological analysis revealed severe neuronal degeneration in the AD group, while MgT-treated groups showed reduced neurodegeneration and improved neuronal integrity.

Discussion: In rats, MgT demonstrates significant neuroprotective, biochemical, and behavioral benefits in an AlCl3-induced AD model. These findings suggest that MgT could be a promising therapeutic agent for AD, warranting further investigation and clinical trials.

Keywords: Alzheimer’s Disease, Magnesium-L-Threonate, Aluminum Chloride, Neuroprotection

Introduction

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder characterized by a decline in memory and cognitive abilities. AD is the most common form of dementia, marked by the accumulation of amyloid-beta peptide (Aβ), which triggers the formation of neuritic plaques and neurofibrillary tangles [1]. Additionally, AD disrupts various neural signaling pathways, particularly the N-methyl-D-aspartate receptor (NMDAR) signaling pathway. NMDAR is a vital calcium channel and glutamate receptor found in neuronal membranes, and its dysfunction is closely associated with AD pathology [2].
In 1906, German neuropathologist and psychiatrist Alois Alzheimer discovered AD. It is the fifth leading cause of death and accounts for 60 to 80 percent of dementia cases [3].
Globally, dementia will impact an estimated 74.7 million people by 2030 and 131.5 million by 2050. While AD can occur in younger individuals, it predominantly affects those over the age of 65 [4].
As a neurodegenerative disease, AD progressively impairs memory and cognition functions, alters behavior, slows thinking, and eventually makes daily tasks unmanageable, requiring full-time care. Early symptoms include difficulties in encoding and recalling new memories, with progressive changes in behavior and cognition as the disease advances [5].
Memory loss, particularly of short-term memory, is often the earliest and most prominent symptom. In later stages, severe memory loss and disorientation occur, impairing even long-term memory. AD typically affects the processing of non-hippocampal memories. In severe late-stage AD, patients often lose the ability to walk, talk, and recognize time and place [6].
The etiology of AD is complex, involving environmental and genetic factors. Key pathological features include amyloid plaques, neurofibrillary tangles (NFTs), and the loss of synapses and neurons [7]. Several hypotheses link mitochondrial DNA mutations or dysfunction to age-related changes and dementia. The oxidative stress hypothesis suggests that amyloid-beta (Aβ) induces oxidative stress, damaging neuronal macromolecules and generating reactive species [8].
The pathogenesis of AD is influenced by a variety of risk factors, including aging, environmental exposures to metals, hereditary factors, cardiovascular diseases, head trauma, and infections [9, 10]. Magnesium, the fourth most abundant element in the human body and the second most abundant intracellular cation, is crucial for numerous biological processes, including brain function. It is a cofactor for more than 600 enzymatic activities, regulates blood pressure and glucose metabolism, and facilitates calcium and potassium transport across cell membranes. Additionally, it is crucial for the conduction of nerve impulses, and its deficiency has been linked to the development of dementia-related disorders, including AD [11].
Adequate magnesium intake, absorption, and metabolism are vital for mental health. MgT from the diet has shown efficacy in increasing brain Mg2+ levels and improving cognitive functions in aged animals. It has demonstrated favorable cognitive effects in animal models of AD [2, 11-12].
Despite numerous efforts to develop treatments for AD, there is currently no cure. However, some medications can manage symptoms and slow the progression of the disease. This study aimed to evaluate the effects of MgT on biochemical, behavioral, and cerebral histopathological changes in rats with AlCl3-induced AD.

Material and Methods

Animals and Experimental Design

Forty Wistar albino rats, aged three months and weighing 200-250 g, were selected from King Fahd Medical Research Center (KFMRC). The rats were housed under standard conditions, with a temperature of 24 ± 1°C, relative humidity of 70%, and a 12-hour light/dark cycle. The study was conducted the ethical guidelines approved by the institutional committee. All rats were provided a standard diet and water ad libitum throughout the six-week experimental period.
The rats were randomly divided into four groups (n = 10 per group):
Control healthy group (C): Rats were injected intraperitoneally (i.p.) with normal saline and received normal saline via oral gavage for six weeks.
AD group (AD): Rats were injected i.p. with AlCl3 (100 mg/kg body weight) [13] daily and received normal saline orally for six weeks.
Positive control group (Mg): Rats received MgT (604 mg/kg body weight/day) [14] daily via oral gavage for six weeks and were treated with normal saline i.p.
Protective group (Pr): Rats were treated with AlCl3 as in the AD group and received MgT (296 mg/kg body weight) orally as in the Mg group for six weeks.

Biochemical Assessment

At the end of the experimental period, all rats were sacrificed by decapitation. Blood samples were collected from the abdominal and thoracic blood vessels. The serum was separated by centrifugation at 3000 rpm for 10 minutes and stored at -80°C until biochemical analysis. The levels of Tau, APP, AchE, GSH, malondialdehyde (MDA), and superoxide dismutase (SOD) were measured using ELISA kits following the manufacturer’s instructions (Glory Science Co. Ltd., USA). Albumin levels were determined using colorimetric methods as described by Lowry et al. [15].

Behavioral Assessment

Head Poking Test

At the end of the six-week treatment period, three rats from each group were subjected to a head-poking behavior study for three days to assess neophilia, anxiety levels and analyze the learning curve [16]. Each rat was placed in the center of an arena and allowed to explore freely. The number of head pokes was recorded, counting consecutive pokes only if the rat fully withdrew its head before poking again. Each session lasted ten minutes.

Histopathological Examination

Three rats from each group were fasted overnight, euthanized, and their brains were removed for histopathological examination. The skull was carefully opened, and the hippocampus was extracted and fixed in 10% neutral buffered formalin. The hippocampal sections were stained with hematoxylin and eosin (H&E) and examined under a light microscope.

Statistical Analysis

Data were expressed as mean ± standard error of the mean (SEM). Statistical analysis was performed using SPSS version 22 (IBM Corp., Armonk, New York, USA). The Shapiro-Wilk test was used to assess the normality of data distributions. One-way ANOVA followed by Tukey’s post hoc test was used for group comparisons. A P-value < 0.05 was considered statistically significant.

Ethical Approval

This study was approved by the Ethics Committee of King Fahd Medical Research Center (KFMRC), King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia (Date: 2022-08-28, No: 256-22).

Results

Head Poking Test

The head-poking behavior was assessed over three days. On the first and second days, the number of pokes was significantly decreased in the AD and Pr groups compared to the C group (P < 0.0001 and P = 0.015 for AD on the first day; P < 0.0001 and P = 0.004 for Pr on the second day). Conversely, the Mg group showed a significant increase in poking numbers on these days compared to the C group (P = 0.024 and P = 0.010, respectively). Additionally, the AD group had significantly fewer pokes than the Mg group on both the first and second days (P < 0.0001 for both).
On the third day, the AD and Pr groups continued to show significantly decreased poking numbers compared to the C group (P < 0.0001 and P = 0.007, respectively), while the Mg group exhibited a significant increase (P = 0.036). Compared to the Mg group, both the AD and Pr groups had significantly fewer pokes (P < 0.0001 and P = 0.023, respectively).

Biochemical Assessment

As shown in Table 1, levels of Tau and APP were significantly elevated in the AD and Pr groups compared to the C group (P < 0.0001 for all). These levels were also significantly higher in the AD group compared to the Mg and Pr groups (P < 0.0001 for all). Albumin levels were significantly lower in the AD group compared to the C, Mg, and Pr groups (P < 0.0001) and significantly higher in the Mg and Pr groups compared to the C group (P < 0.0001 for both).
GSH and SOD levels were significantly reduced in the AD and Pr groups compared to the C group (P < 0.0001 for all) and were also significantly lower in the AD group compared to the Mg and Pr groups (P < 0.0001 for all). AchE levels were significantly increased in the AD and Pr groups compared to the C group (P < 0.0001 for all) and in the AD group compared to the Mg and Pr groups (P < 0.0001 and P = 0.002) but were significantly decreased in the Mg group compared to the C group (P = 0.026). MDA levels were significantly higher in the AD group compared to the C group (P < 0.0001 for all).

Histopathological Assessment

Histopathological analysis of the hippocampus from the different study groups (C, AD, Mg, and Pr) revealed significant morphological differences. The control (C) and Mg groups showed a normal hippocampal structure with few degenerated cells. The Pr group exhibited potential therapeutic effects, with some aluminum mobilization from the brain, supporting the biochemical findings. In contrast, the AD group showed pronounced degenerative changes in hippocampal neurons, with cells appearing smaller, shrunken, and deformed, exhibiting dark cytoplasm and small, dark nuclei.

Discussion

This study offers a comprehensive analysis of the neuroprotective, biochemical, and behavioral effects of MgT in an AD model induced by AlCl3 in rats. Aluminum (Al) can cause neurotoxicity by generating free radicals, leading to lipid and protein damage through peroxidation. Chronic exposure to Al has a strong affinity for cell membranes and can stimulate the formation and accumulation of insoluble Aβ plaques and neurofibrillary tangles (NFTs) in the brains of individuals with AD [17].
Recent research has increasingly focused on the role of magnesium (Mg) in dementia and other neurodegenerative diseases such as AD. There are two primary hypotheses regarding Mg’s function in dementia. The first hypothesis suggests that Mg directly regulates NMDA receptors, which are ionotropic glutamatergic receptors, by partially blocking the receptor and obstructing calcium channels during neurotransmission. The second hypothesis posits that low levels of Mg2+ stimulate the release of inflammatory substances, such as interleukins, TNF-α, and nitric oxide, which may increase the risk of developing AD [18].
The results of this study highlight the potential of MgT to mitigate the harmful effects of AD through several mechanisms. Mg2+ protects neurons by (1) inhibiting voltage-gated calcium channels and dilating blood vessels; (2) blocking NMDA receptor calcium channels to prevent calcium influx; (3) reducing the production and enhancing the scavenging of free radicals after tissue damage; (4) ameliorating mitochondrial dysfunction, thereby reducing damage caused by impaired energy metabolism; and (5) reducing neuroinflammation by downregulating proinflammatory cytokines [11].
Mg is essential for numerous enzymatic reactions and is critical for synaptic plasticity and neurotransmission. MgT’s ability to cross the blood-brain barrier effectively increases brain Mg levels, which is crucial for enhancing synaptic plasticity and improving cognitive functions [11].
Behavioral assessments using the head-poking test demonstrated MgT’s impact on cognitive function and anxiety levels. The AD group showed significantly reduced head-poking behavior across all three days of testing, reflecting increased anxiety and cognitive impairment. In contrast, the MgT group showed increased head-poking behavior, indicating reduced anxiety and improved cognitive function. These findings align with previous studies reporting the cognitive-enhancing effects of MgT in AD models [12].
Histopathological examination of the hippocampal neurons revealed significant differences between the treatment groups. The C and Mg groups exhibited normal neuronal structures with few degenerated cells. In contrast, the AD group showed marked neuronal degeneration, characterized by shrunken neurons with dark cytoplasm and nuclei, indicating severe neurodegeneration. The Pr group, which received both AlCl3 and MgT, showed fewer degenerative changes compared to the AD group, suggesting that MgT provides partial neuroprotection even in the presence of AlCl3-induced toxicity. These findings are consistent with previous studies demonstrating the neuroprotective effects of magnesium in neurodegenerative conditions [2].
Biochemical assessments revealed significant alterations in key biomarkers associated with AD. The AD group exhibited elevated levels of APP and Tau protein, hallmark features of AD pathology. These elevations were significantly reduced in the MgT and Pr groups, indicating that MgT can mitigate the pathological accumulation of these proteins. This suggests that MgT may interfere with the amyloidogenic pathway and tau phosphorylation, thereby reducing the formation of amyloid plaques and neurofibrillary tangles [1].
Oxidative stress (OS) markers also showed significant differences between the groups. The AD group had increased levels of MDA, a marker of lipid peroxidation, and decreased levels of antioxidants such as GSH and SOD. These changes indicate enhanced OS in AD. In contrast, the MgT group exhibited significantly lower MDA levels and higher levels of GSH and SOD, suggesting that MgT has a potent antioxidant effect. This supports the OS hypothesis of AD, which posits that oxidative damage plays a crucial role in the disease’s progression [8].
The accumulation of toxic oligomers of Aβ in the brain due to inadequate clearance from interstitial fluid (ISF) may be a cause of AD. Albumin, the primary carrier of Aβ in the blood, changes with aging and neurodegeneration. Low serum albumin is associated with cognitive impairment in the elderly [19]. This supports MgT’s ability to improve cognitive function, reduce oxidative stress, and protect neuronal integrity, making it a compelling candidate for further research and clinical trials. Additionally, the safety profile of MgT as a dietary supplement adds to its potential as a feasible and accessible treatment option [12]. The findings of this study have significant clinical implications. Currently, there is no cure for AD, and available treatments mainly focus on symptom management. The identification of MgT as a potential therapeutic agent offers a promising avenue for AD treatment.
Conclusion

In summary, MgT shows substantial neuroprotective, biochemical, and behavioral benefits in an AD model induced by AlCl3 in rats. These results indicate that MgT holds promise as a therapeutic agent for AD, meriting further research and clinical trials. This study contributes to the expanding body of evidence supporting the role of magnesium in brain health and its potential in combating neurodegenerative diseases.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and Human Rights Statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or compareable ethical standards.

Funding: None

Conflict of Interest

The authors declare that there is no conflict of interest.

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Maha Jameal Balgoon. Exploring neuroprotective, biochemical, and behavioral effects of Magnesium Threonate in Alzheimer’s induced by aluminum chloride in rats. Ann Clin Anal Med 2024;15(9):645-649

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