To determine the efficacy of high frequency cerebellar repetitive transcranial magnetic stimulation on coordination in patients with multiple sclerosis.

Forty patients with multiple sclerosis suffering from ataxia less than five in EDSS score will be recruited from the outpatient clinic at Faculty of Physical Therapy as well as Kasr Al-Ainy Multiple Sclerosis unit (KAMSU), Cairo University. The study will be applied during the remission period. Patients will be assessed by Biodex balance system, Berg balance scale, Four square step test and Nine-Hole Peg Test to investigate coordination in both equilibrium and non-equilibrium. Patient will be divided into two groups.The study group will be treated by High frequecy cerebellar repetitive transcranial magnetic stimulation besides a tailored physiotherapy program, while the control group will be treated by Sham cerebellar repetitive transcranial magnetic stimulation with a tailored physiotherapy program as well. The treatment duration for each patient will take weeks.

Inclusion Criteria:

• Clinically definite MS (relapsing, remitting and secondary progressive) patients
• Patients who are medically stable and Free from relapses three months before
• Ambulant patients without an assistive device and score less than 5 on the Kurtzke Expanded Disability Status Scale (EDSS)
• Patients receiving their disease modifying drugs but no medication changing during the previous three months.
• Patients who had MRI evidence of lesions in the cerebellum or in the cerebellar pedunculi.
• Right handed patients.
• Severity of ataxia range from 4 to 10 according to scale of assessment and rating ataxia (SARA).
• Did not apply cerebellar transcranial magnetic stimulation before.

Exclusion Criteria:

• Any other neurological deficits or orthopedics abnormalities.
• Ataxic manifestations for other cause rather than Multiple Sclerosis.
• Other neurological manifestations (e.g. spasticity, visual loss)
• Secondary musculoskeletal complication such as contractures or deformities. Cardiovascular, pulmonary, hepatic, renal, hemopoietic and thyroid diseases.
• Pregnant women.
• Addicted individuals.
• Previous surgeries in the brain.
• Any magnetic or metallic devices implanted (like cochlear implants) .
• Psychotic deficits or history of epileptic seizures.

Participant masking as patients will be divided into two groups High frequecy cerebellar repetitive transcranial magnetic stimulation and Sham repetitive transcranial magnetic stimulation by placing the coil in perpendicular way away from the cerebellum.

Care provider masking as the physical therapist treating patients will be blind from the application of repetitive transcranial magnetic stimulation