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Machamer JB, Vazquez-Cintron EJ, O'Brien SW, Kelly KE, Altvater AC, Pagarigan KT, Dubee PB, Ondeck CA, McNutt PM. Antidotal treatment of botulism in rats by continuous infusion with 3,4-diaminopyridine. Mol Med 2022; 28:61. [PMID: 35659174 PMCID: PMC9164507 DOI: 10.1186/s10020-022-00487-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
Botulinum neurotoxins (BoNTs) are highly potent, select agent toxins that inhibit neurotransmitter release at motor nerve terminals, causing muscle paralysis and death by asphyxiation. Other than post-exposure prophylaxis with antitoxin, the only treatment option for symptomatic botulism is intubation and supportive care until recovery, which can require weeks or longer. In previous studies, we reported the FDA-approved drug 3,4-diaminopyridine (3,4-DAP) reverses early botulism symptoms and prolongs survival in lethally intoxicated mice. However, the symptomatic benefits of 3,4-DAP are limited by its rapid clearance. Here we investigated whether 3,4-DAP could sustain symptomatic benefits throughout the full course of respiratory paralysis in lethally intoxicated rats. First, we confirmed serial injections of 3,4-DAP stabilized toxic signs and prolonged survival in rats challenged with 2.5 LD50 BoNT/A. Rebound of toxic signs and death occurred within hours after the final 3,4-DAP treatment, consistent with the short half-life of 3,4-DAP in rats. Based on these data, we next investigated whether the therapeutic benefits of 3,4-DAP could be sustained throughout the course of botulism by continuous infusion. To ensure administration of 3,4-DAP at clinically relevant doses, three infusion dose rates (0.5, 1.0 and 1.5 mg/kg∙h) were identified that produced steady-state serum levels of 3,4-DAP consistent with clinical dosing. We then compared dose-dependent effects of 3,4-DAP on toxic signs and survival in rats intoxicated with 2.5 LD50 BoNT/A. In contrast to saline vehicle, which resulted in 100% mortality, infusion of 3,4-DAP at ≥ 1.0 mg/kg∙h from 1 to 14 d after intoxication produced 94.4% survival and full resolution of toxic signs, without rebound of toxic signs after infusion was stopped. In contrast, withdrawal of 3,4-DAP infusion at 5 d resulted in re-emergence of toxic sign and death within 12 h, confirming antidotal outcomes require sustained 3,4-DAP treatment for longer than 5 d after intoxication. We exploited this novel survival model of lethal botulism to explore neurophysiological parameters of diaphragm paralysis and recovery. While neurotransmission was nearly eliminated at 5 d, neurotransmission was significantly improved at 21 d in 3,4-DAP-infused survivors, although still depressed compared to naïve rats. 3,4-DAP is the first small molecule to reverse systemic paralysis and promote survival in animal models of botulism, thereby meeting a critical treatment need that is not addressed by post-exposure prophylaxis with conventional antitoxin. These data contribute to a growing body of evidence supporting the use of 3,4-DAP to treat clinical botulism.
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Affiliation(s)
- James B Machamer
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
- BASF, Research Triangle, Durham, NC, 27709, USA
| | | | - Sean W O'Brien
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27101, USA
| | - Kyle E Kelly
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
| | - Amber C Altvater
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
| | - Kathleen T Pagarigan
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
| | - Parker B Dubee
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
| | - Celinia A Ondeck
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27101, USA
| | - Patrick M McNutt
- U.S. Army Medical Research Institute of Chemical Defense, Gunpowder, MD, 21010, USA.
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, 27101, USA.
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Ye F, Yang B, Nam C, Xie Y, Chen F, Hu X. A Data-Driven Investigation on Surface Electromyography Based Clinical Assessment in Chronic Stroke. Front Neurorobot 2021; 15:648855. [PMID: 34335219 PMCID: PMC8320436 DOI: 10.3389/fnbot.2021.648855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 06/14/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Surface electromyography (sEMG) based robot-assisted rehabilitation systems have been adopted for chronic stroke survivors to regain upper limb motor function. However, the evaluation of rehabilitation effects during robot-assisted intervention relies on traditional manual assessments. This study aimed to develop a novel sEMG data-driven model for automated assessment. Method: A data-driven model based on a three-layer backpropagation neural network (BPNN) was constructed to map sEMG data to two widely used clinical scales, i.e., the Fugl-Meyer Assessment (FMA) and the Modified Ashworth Scale (MAS). Twenty-nine stroke participants were recruited in a 20-session sEMG-driven robot-assisted upper limb rehabilitation, which consisted of hand reaching and withdrawing tasks. The sEMG signals from four muscles in the paretic upper limbs, i.e., biceps brachii (BIC), triceps brachii (TRI), flexor digitorum (FD), and extensor digitorum (ED), were recorded before and after the intervention. Meanwhile, the corresponding clinical scales of FMA and MAS were measured manually by a blinded assessor. The sEMG features including Mean Absolute Value (MAV), Zero Crossing (ZC), Slope Sign Change (SSC), Root Mean Square (RMS), and Wavelength (WL) were adopted as the inputs to the data-driven model. The mapped clinical scores from the data-driven model were compared with the manual scores by Pearson correlation. Results: The BPNN, with 15 nodes in the hidden layer and sEMG features, i.e., MAV, ZC, SSC, and RMS, as the inputs to the model, was established to achieve the best mapping performance with significant correlations (r > 0.9, P < 0.001), according to the FMA. Significant correlations were also obtained between the mapped and manual FMA subscores, i.e., FMA-wrist/hand and FMA-shoulder/elbow, before and after the intervention (r > 0.9, P < 0.001). Significant correlations (P < 0.001) between the mapped and manual scores of MASs were achieved, with the correlation coefficients r = 0.91 at the fingers, 0.88 at the wrist, and 0.91 at the elbow after the intervention. Conclusion: An sEMG data-driven BPNN model was successfully developed. It could evaluate upper limb motor functions in chronic stroke and have potential application in automated assessment in post-stroke rehabilitation, once validated with large sample sizes. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02117089.
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Affiliation(s)
- Fuqiang Ye
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
- Department of Electrical and Electronic Engineering, Southern University of Science and Technology, Shenzhen, China
| | - Bibo Yang
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Chingyi Nam
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Yunong Xie
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
| | - Fei Chen
- Department of Electrical and Electronic Engineering, Southern University of Science and Technology, Shenzhen, China
| | - Xiaoling Hu
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China
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Ishida N, Kondo Y, Chikano Y, Kobayashi‐Nakade E, Suga Y, Ishizaki J, Komai K, Matsushita R. Pharmacokinetics and tissue distribution of 3,4‐diaminopyridine in rats. Biopharm Drug Dispos 2019; 40:294-301. [DOI: 10.1002/bdd.2203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Revised: 07/12/2019] [Accepted: 08/09/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Natsuko Ishida
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
- Department of Clinical Research, Iou National HospitalNational Hospital Organization Ishikawa Japan
| | - Yuya Kondo
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
| | - Yuri Chikano
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
| | - Erina Kobayashi‐Nakade
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
| | - Yukio Suga
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
| | - Junko Ishizaki
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
| | - Kiyonobu Komai
- Department of Neurology, Hokuriku Brain and Neuromuscular Disease Center, Iou National HospitalNational Hospital Organization Ishikawa Japan
| | - Ryo Matsushita
- Faculty of Pharmacy, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Kakuma‐machi Kanazawa Ishikawa 920‐1192 Japan
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Peikert K, Naumann M, Günther R, Wegner F, Hermann A. Off-Label Treatment of 4 Amyotrophic Lateral Sclerosis Patients With 4-Aminopyridine. J Clin Pharmacol 2019; 59:1400-1404. [PMID: 31038230 DOI: 10.1002/jcph.1437] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/11/2019] [Indexed: 02/06/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal disorder characterized by degeneration of the upper and lower motor neuron. Among the at least 25 known genes associated with familial (hereditary) and sporadic ALS, mutations in fused-in-sarcoma (FUS) and superoxide dismutase 1 (SOD1) have been extensively investigated in the past years, with emphasis on altered excitability of affected neurons. Recently, we reported on hypoexcitability and increased cell death in a FUS/SOD1-ALS-induced pluripotent stem cell-derived motor neuron model, which was partly reversible by a treatment with the potassium channel blocker 4-aminopyridine (4-AP). Based on this study, we aimed to examine this US Food and Drug Administration-approved drug as a potential individualized treatment for patients with ALS. We therefore retrospectively investigated 4 FUS/SOD1-ALS patients who were prescribed 4-AP. Two patients expressed an improved quality of life due to regain of facial muscle motor function and decreased disease progression rate, respectively. Together with recent pathophysiologic findings, this case series supports the need for clinical trials to examine the efficacy of this potential treatment in distinct ALS subgroups and disease stages.
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Affiliation(s)
- Kevin Peikert
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcel Naumann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,DZNE, German Centre for Neurodegenerative Diseases, Research Site Dresden, Dresden, Germany.,Translational Neurodegeneration Section Albrecht Kossel, Department of Neurology, University Medical Center Rostock, University of Rostock, Rostock, Germany
| | - René Günther
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,DZNE, German Centre for Neurodegenerative Diseases, Research Site Dresden, Dresden, Germany
| | - Florian Wegner
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Andreas Hermann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,DZNE, German Center for Neurodegenerative Diseases, Research Site Rostock/Greifswald, Rostock, Germany.,Translational Neurodegeneration Section Albrecht Kossel, Department of Neurology, University Medical Center Rostock, University of Rostock, Rostock, Germany.,Center for Transdisciplinary Neurosciences Rostock (CTNR), University Medical Center Rostock, University of Rostock, Rostock, Germany
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Tarr TB, Lacomis D, Reddel SW, Liang M, Valdomir G, Frasso M, Wipf P, Meriney SD. Complete reversal of Lambert-Eaton myasthenic syndrome synaptic impairment by the combined use of a K+ channel blocker and a Ca2+ channel agonist. J Physiol 2014; 592:3687-96. [PMID: 25015919 DOI: 10.1113/jphysiol.2014.276493] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Lambert-Eaton myasthenic syndrome (LEMS) is an autoimmune disorder in which a significant fraction of the presynaptic P/Q-type Ca(2+) channels critical to the triggering of neurotransmitter release at the neuromuscular junction (NMJ) are thought to be removed. There is no cure for LEMS, and the current most commonly used symptomatic treatment option is a potassium channel blocker [3,4-diaminopyridine (3,4-DAP)] that does not completely reverse symptoms and can have dose-limiting side-effects. We previously reported the development of a novel Ca(2+) channel agonist, GV-58, as a possible alternative treatment strategy for LEMS. In this study, we tested the hypothesis that the combination of GV-58 and 3,4-DAP will elicit a supra-additive increase in neurotransmitter release at LEMS model NMJs. First, we tested GV-58 in a cell survival assay to assess potential effects on cyclin-dependent kinases (Cdks) and showed that GV-58 did not affect cell survival at the relevant concentrations for Ca(2+) channel effects. Then, we examined the voltage dependence of GV-58 effects on Ca(2+) channels using patch clamp techniques; this showed the effects of GV-58 to be dependent upon Ca(2+) channel opening. Based on this mechanism, we predicted an interaction between 3,4-DAP and GV-58. We tested this hypothesis using a mouse passive transfer model of LEMS. Using intracellular electrophysiological ex vivo recordings, we demonstrated that a combined application of 3,4-DAP plus GV-58 had a supra-additive effect that completely reversed the deficit in neurotransmitter release magnitude at LEMS model NMJs. This reversal contrasts with the less significant improvement observed with either compound alone. Our data indicate that a combination of 3,4-DAP and GV-58 represents a promising treatment option for LEMS and potentially for other disorders of the NMJ.
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Affiliation(s)
- Tyler B Tarr
- Department of Neuroscience, Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA
| | - David Lacomis
- Division of Neuromuscular Diseases, Department of Neurology, University of Pittsburgh, Pittsburgh, PA, USA Department of Pathology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen W Reddel
- Department of Clinical Neurology, Concord Hospital, Sydney, NSW, Australia
| | - Mary Liang
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA Center for Chemical Methodologies and Library Development, University of Pittsburgh, Pittsburgh, PA, USA
| | - Guillermo Valdomir
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA Center for Chemical Methodologies and Library Development, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael Frasso
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA Center for Chemical Methodologies and Library Development, University of Pittsburgh, Pittsburgh, PA, USA
| | - Peter Wipf
- Department of Chemistry, University of Pittsburgh, Pittsburgh, PA, USA Center for Chemical Methodologies and Library Development, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen D Meriney
- Department of Neuroscience, Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA, USA Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA, USA
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Pagnini F, Manzoni GM, Tagliaferri A, Gibbons CJ. Depression and disease progression in amyotrophic lateral sclerosis: A comprehensive meta-regression analysis. J Health Psychol 2014; 20:1107-28. [PMID: 24764286 DOI: 10.1177/1359105314530453] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Depression in people with amyotrophic lateral sclerosis, a fatal and progressive neurodegenerative disorder, is a serious issue with important clinical consequences. However, physical impairment may confound the diagnosis when using generic questionnaires. We conducted a comprehensive review of literature. Mean scores from depression questionnaires were meta-regressed on study-level mean time since onset of symptoms. Data from 103 studies (3190 subjects) indicate that the Beck Depression Inventory and, to a lesser degree, the Hospital Anxiety and Depression Scale are influenced by the time since symptom onset, strongly related to physical impairment. Our results suggest that widely used depression scales overestimate depression due to confounding with physical symptoms.
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Affiliation(s)
- Francesco Pagnini
- Department of Psychology, Catholic University of Milan, Italy Azienda Ospedaliera Niguarda Ca' Granda, Italy
| | - Gian Mauro Manzoni
- Department of Psychology, Catholic University of Milan, Italy San Giuseppe Hospital, Istituto Auxologico Italiano, Italy
| | | | - Chris J Gibbons
- NIHR Collaboration for Applied Health Research and Care (CLAHRC-GM), University of Manchester, Manchester, UK Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, UK
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Abstract
Aminopyridines are members of a family of monoamino and diamino derivatives of pyridine, and their principal mechanism of action is dose-dependent blockade of voltage-gated potassium channels, in particular, fast voltage-gated potassium channels. To date, only 2 main broad-spectrum potassium channel blockers, 4-aminopyridine (4-AP) and 3,4-diaminopyridine (3,4-DAP), have been used as investigational new drugs in various neurological diseases. More recently, licensed versions of these compounds including dalfampridine extended release (Fampyra, Biogen Idec) for the improvement of walking in adult patients with multiple sclerosis, and amifampridine (Firdapse, Biomarin Europe Ltd) for the treatment of Lambert-Eaton myasthenic syndrome have been released, and the costs associated with using these new products highlights the importance of evaluating the clinically meaningful treatment effects of these drugs.The current review summarizes the evidence of aminopyridine use in neurological conditions and in particular presents a systematic review of all randomized trials of 3,4-DAP in Lambert-Eaton myasthenic syndrome to determine the efficacy of this treatment using meta-analysis of clinical and electrophysiological end points.
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Adler M, Deshpande SS, Apland JP, Murray B, Borrell A. Reversal of BoNT/A-mediated inhibition of muscle paralysis by 3,4-diaminopyridine and roscovitine in mouse phrenic nerve-hemidiaphragm preparations. Neurochem Int 2012; 61:866-73. [PMID: 22841859 DOI: 10.1016/j.neuint.2012.07.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 07/02/2012] [Accepted: 07/09/2012] [Indexed: 12/31/2022]
Abstract
Botulinum neurotoxins (BoNTs) comprise a family of neurotoxic proteins synthesized by anaerobic bacteria of the genus Clostridium. Each neurotoxin consists of two polypeptide chains: a 100kDa heavy chain, responsible for binding and internalization into the nerve terminal of cholinergic motoneurons and a 50kDa light chain that mediates cleavage of specific synaptic proteins in the host nerve terminal. Exposure to BoNT leads to cessation of voltage- and Ca(2+)-dependent acetylcholine (ACh) release, resulting in flaccid paralysis which may be protracted and potentially fatal. There are no approved therapies for BoNT intoxication once symptoms appear, and specific inhibitors of the light chain developed to date have not been able to reverse the consequences of BoNT intoxication. An alternative approach for treatment of botulism is to focus on compounds that act by enhancing ACh release. To this end, we examined the action of the K(+) channel blocker 3,4-diaminopyridine (3,4-DAP) in isolated mouse hemidiaphragm muscles intoxicated with 5pM BoNT/A. 3,4-DAP restored tension within 1-3min of application, and was effective even in totally paralyzed muscle. The Ca(2+) channel activator (R)-roscovitine (Ros) potentiated the action of 3,4-DAP, allowing for use of lower concentrations of the K(+) channel blocker. In the absence of 3,4-DAP, Ros was unable to augment tension in BoNT/A-intoxicated muscle. This is the first report demonstrating the efficacy of the combination of 3,4-DAP and Ros for the potential treatment of BoNT/A-mediated muscle paralysis.
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Affiliation(s)
- Michael Adler
- Neurobehavioral Toxicology Branch, Analytical Toxicology Division, U.S. Army Medical Research Institute of Chemical Defense, 3100 Ricketts Point Road, APG, MD 21010-5400, USA.
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Baldinger R, Katzberg HD, Weber M. Treatment for cramps in amyotrophic lateral sclerosis/motor neuron disease. Cochrane Database Syst Rev 2012:CD004157. [PMID: 22513921 DOI: 10.1002/14651858.cd004157.pub2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cramps are painful, involuntary muscle contractions. They commonly affect people with amyotrophic lateral sclerosis/motor neuron disease (ALS/MND) at all stages of the disease. To date, the treatment of muscle cramps in ALS has been largely empirical without any evidence from randomised controlled trials. OBJECTIVES To systematically assess the effect of interventions on muscle cramps as a primary or secondary endpoint or adverse event in people with ALS/MND. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register (14 February 2011), the Cochrane Central Register of Controlled Trials (Issue 1, 2011 in The Cochrane Library), MEDLINE (January 1966 to January 2011) and EMBASE (January 1980 to January 2011) and reference lists of articles searched using the terms motor neuron disease, motor neurone disease, motoneuron disease or amyotrophic lateral sclerosis. We contacted authors of trials for further information. SELECTION CRITERIA We included all randomised and quasi-randomised trials of oral medications in people with ALS which assessed cramps as a primary or secondary outcome measure or as an adverse event. We also included trials using subcutaneous or intravenous medications or physical therapy. DATA COLLECTION AND ANALYSIS All authors applied the selection criteria and assessed study quality independently, and all authors performed independent data extraction. MAIN RESULTS Twenty studies including 4789 participants were identified. Only one trial, of tetrahydrocannabinol (THC), assessed cramps as the primary endpoint. Thirteen studies assessed cramps as a secondary endpoint. The medications comprised vitamin E, baclofen, riluzole, L-threonine, xaliproden, indinavir, and memantine. Six studies assessed cramps as an adverse event. The medications comprised creatine, gabapentin, dextromethorphan, quinidine, and lithium. In all 20 studies no favourable effect for the treatment of cramps in ALS/MND could be demonstrated, but many studies were underpowered to draw a definite conclusion. A meta-analysis of two small studies showed a statistically nonsignificant result for the amino acid L-threonine for the treatment of cramps in ALS/MND. No study was identified using physical therapy as a therapeutic intervention for cramps. AUTHORS' CONCLUSIONS There is no evidence to support the use of any intervention for muscle cramps in ALS/MND. More and larger randomised controlled trials evaluating treatments for muscle cramps in ALS/MND are needed.
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Affiliation(s)
- Reto Baldinger
- Muskelzentrum/ALS Clinic, Kantonsspital St. Gallen, St. Gallen, Switzerland
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Abstract
OBJECTIVE To study the safety of 3-4 diaminopyridine (DAP) in patients with motor neuron diseases and to examine its efficacy in reducing muscle fatigue and weakness and in improving objective parameters of muscle function. DESIGN Assessments of safety included a questionnaire of symptoms, clinical examination, blood testing, and electrocardiography at each visit; efficacy was assessed by subjective scores of fatigue and weakness; an Amyotrophic Lateral Sclerosis Functional Rating Scale and functional ability scores, including timed verbal scores; manual muscle testing; grip dynamometry; pulmonary function tests; timed functional tests; and electrophysiological studies. PARTICIPANTS Thirteen subjects with amyotrophic lateral sclerosis and seven subjects with only a lower motor neuron syndrome. MAIN OUTCOMES Assess tolerability of DAP and determine if there was symptomatic improvement of muscle fatigue. SECONDARY OUTCOME: To determine the effects of DAP on objective parameters of muscle function. RESULTS The drug was well tolerated with only four subjects reporting tingling of lips and fingers during the active drug period. The subjective scores for fatigue and weakness showed a mild improvement after 4 weeks on DAP compared with placebo. A significant benefit of DAP was also demonstrated in the timed verbal scores. CONCLUSION 3-4 DAP appeared to be safe and produced subjective benefit in motor neuron diseases. The drug could be added for symptomatic treatment in these diseases. Larger studies are necessary to demonstrate efficacy.
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De Groot IJM, Post MWM, Van Heuveln T, Van Den Berg LH, Lindeman E. Measurement of decline of functioning in persons with amyotrophic lateral sclerosis: responsiveness and possible applications of the Functional Independence Measure, Barthel Index, Rehabilitation Activities Profile and Frenchay Activities Index. ACTA ACUST UNITED AC 2006; 7:167-72. [PMID: 16963406 DOI: 10.1080/14660820600640620] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
It is important not only to monitor the functional change during the course of ALS, but also to determine whether or not the available help is sufficient. This study was performed to determine which generic assessment instrument is most appropriate. A multicentre cohort of patients with ALS was followed for one year. At baseline, six months, and 1 year four instruments were used: Functional Independence Measure (FIM), Rehabilitation Activities Profile (RAP), Barthel Index (BI), and Frenchay Activities Index (FAI). The responsiveness of the measures was examined using effect sizes and standardized response mean statistics. Seventy-three patients at baseline, 63 after six months and 43 after one year were assessed. If calculated on the group that completed all three assessments, the FIM, BI, and RAP showed moderate effect sizes and standardized response means over a period of six months and large effect sizes over 12 months. Based on their responsiveness FIM, BI, and RAP can be used to evaluate limitations in activities and care needs of persons with ALS and to evaluate treatment results in trials. The FIM was the most responsive instrument, although the BI might be easier to use in clinical practice.
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12
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Krebs HI, Ferraro M, Buerger SP, Newbery MJ, Makiyama A, Sandmann M, Lynch D, Volpe BT, Hogan N. Rehabilitation robotics: pilot trial of a spatial extension for MIT-Manus. J Neuroeng Rehabil 2004; 1:5. [PMID: 15679916 PMCID: PMC544952 DOI: 10.1186/1743-0003-1-5] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Accepted: 10/26/2004] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND: Previous results with the planar robot MIT-MANUS demonstrated positive benefits in trials with over 250 stroke patients. Consistent with motor learning, the positive effects did not generalize to other muscle groups or limb segments. Therefore we are designing a new class of robots to exercise other muscle groups or limb segments. This paper presents basic engineering aspects of a novel robotic module that extends our approach to anti-gravity movements out of the horizontal plane and a pilot study with 10 outpatients. Patients were trained during the initial six-weeks with the planar module (i.e., performance-based training limited to horizontal movements with gravity compensation). This training was followed by six-weeks of robotic therapy that focused on performing vertical arm movements against gravity. The 12-week protocol includes three one-hour robot therapy sessions per week (total 36 robot treatment sessions). RESULTS: Pilot study demonstrated that the protocol was safe and well tolerated with no patient presenting any adverse effect. Consistent with our past experience with persons with chronic strokes, there was a statistically significant reduction in tone measurement from admission to discharge of performance-based planar robot therapy and we have not observed increases in muscle tone or spasticity during the anti-gravity training protocol. Pilot results showed also a reduction in shoulder-elbow impairment following planar horizontal training. Furthermore, it suggested an additional reduction in shoulder-elbow impairment following the anti-gravity training. CONCLUSION: Our clinical experiments have focused on a fundamental question of whether task specific robotic training influences brain recovery. To date several studies demonstrate that in mature and damaged nervous systems, nurture indeed has an effect on nature. The improved recovery is most pronounced in the trained limb segments. We have now embarked on experiments that test whether we can continue to influence recovery, long after the acute insult, with a novel class of spatial robotic devices. This pilot results support the pursuit of further clinical trials to test efficacy and the pursuit of optimal therapy following brain injury.
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Affiliation(s)
- Hermano I Krebs
- Massachusetts Institute of Technology, Mechanical Engineering Department, Cambridge, MA, USA
- Weill Medical College of Cornell University, Department Neurology and Neuroscience, New York, NY, USA
| | - Mark Ferraro
- Burke Medical Research Institute, White Plains, NY, USA
| | - Stephen P Buerger
- Massachusetts Institute of Technology, Mechanical Engineering Department, Cambridge, MA, USA
| | - Miranda J Newbery
- Massachusetts Institute of Technology, Mechanical Engineering Department, Cambridge, MA, USA
- Imperial College, London, UK
| | | | | | - Daniel Lynch
- Burke Medical Research Institute, White Plains, NY, USA
| | - Bruce T Volpe
- Weill Medical College of Cornell University, Department Neurology and Neuroscience, New York, NY, USA
- Burke Medical Research Institute, White Plains, NY, USA
| | - Neville Hogan
- Massachusetts Institute of Technology, Mechanical Engineering Department, Cambridge, MA, USA
- Massachusetts Institute of Technology, Brain and Cognitive Sciences, Cambridge, MA, USA
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Daly JJ, Ruff RL. Feasibility of combining multi-channel functional neuromuscular stimulation with weight-supported treadmill training. J Neurol Sci 2004; 225:105-15. [PMID: 15465093 DOI: 10.1016/j.jns.2004.07.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2004] [Revised: 06/30/2004] [Accepted: 07/02/2004] [Indexed: 11/24/2022]
Abstract
More than 3 million stroke survivors live with residual disabilities and mobility deficits even after rehabilitation. Therefore, it is important to develop new, more effective, gait training methods. The purpose of this study was twofold: (1) testing the feasibility of combining multi-channel functional neuromuscular stimulation (FNS) using intramuscular (IM) electrodes and body weight supported treadmill training (BWSTT) for gait training; and (2) documenting the potential gait practice advantages afforded by combining FNS-IM and BWSTT. Eight subjects with gait deficits in the chronic phase (>12 months) were enrolled. Intramuscular electrodes were placed in the paretic hip abductors, knee flexors and extensors, and ankle dorsiflexors, plantarflexors, and evertors. Subjects were treated with exercise and gait training using the combined technologies 1 1/2 h/week, four times/week, for 12 weeks. Feasibility was tested according to performance of the technologies, clinician skill factors, and subject satisfaction. Impairment, function, and quality of life were measured. Provision of practice for eight gait characteristics was catalogued. We found the following results for the combined technologies: (1) the combined technologies were safe and feasible; (2) clinicians required five training sessions to reach proficiency; (3) subjects were satisfied; (4) there were significant gains in impairment and functional measures; (5) a greater number of gait practice characteristics were provided with the combined technologies than with either alone.
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Affiliation(s)
- Janis J Daly
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH 44106, USA.
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Ferraro M, Demaio JH, Krol J, Trudell C, Rannekleiv K, Edelstein L, Christos P, Aisen M, England J, Fasoli S, Krebs HI, Hogan N, Volpe BT. Assessing the motor status score: a scale for the evaluation of upper limb motor outcomes in patients after stroke. Neurorehabil Neural Repair 2002; 16:283-9. [PMID: 12234090 DOI: 10.1177/154596830201600306] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Motor Status Scale (MSS) measures shoulder, elbow (maximum score = 40), wrist, hand, and finger movements (maximum score = 42), and expands the measurement of upper extremity impairment and disability provided by the Fugl-Meyer (FM) score. This work examines the interrater reliability and criterion validity of the MSS performed in patients admitted to a rehabilitation hospital 21 +/- 4 days after stroke. Using the MSS and the FM, 7 occupational therapists masked to each other's judgments, evaluated 12 consecutive patients with stroke. Two therapists evaluated 6 additional patients on consecutive days. Intraclass correlation coefficients were significant for each group of raters for the shoulder/elbow and for the wrist/band (P < 0.0001); test-retest measures were also significant for the shoulder/elbow (Pearson correlation coefficient r = 0.99, P < 0.004) and for the wrist/hand (Pearson correlation coefficient r = 0.99, P < 0.003). The internal item consistency for the overall MSS was significant (Cronbach alpha = 0.98, P < 0.0001). Finally the correlation between the MSS and the FM (R2 = 0.964) was significant (P < 0.0001). The MSS affords a reliable and valid assessment of upper limb impairment and disability following stroke.
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Affiliation(s)
- Mark Ferraro
- Burke Medical Research Institute, Burke Rehabilitation Hospital, White Plains, NY, USA
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Gibaud S, Bonneville A, Astier A. Preparation of 3,4-diaminopyridine microparticles by solvent-evaporation methods. Int J Pharm 2002; 242:197-201. [PMID: 12176246 DOI: 10.1016/s0378-5173(02)00157-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The present study compares two methods of preparation of microparticles of 3,4-diaminopyridine (3,4-DAP) for the treatment for multiple sclerosis and Lambert-Eaton myasthenia syndrome. Poly( epsilon -caprolactone) microparticles were prepared with a solvent-evaporation W/O method. The 3,4-DAP was dispersed in dichloromethane, leading to a suspension. The dispersion and the solidification of the dichloromethane droplets in an aqueous phase have led to microparticles of 55.3+/-34.7 microm. The incorporation of the drug by milligram of powder was very low (1.91 micrograms/mg) and the scanning electron microscopy (SEM) did not show any crystal but marks of dissolved crystals were observed on the polymeric surface. EudragitRS microspheres containing 3,4-DAP were prepared by a solvent-evaporation technique using light mineral oil as continuous phase. The drug and the polymer were completely dissolved in an acetone solution, used as discontinuous phase. This formulation have led to a higher incorporation of the drug (88.25 micrograms/mg). The particle size was 91.8+/-44.3 microm. The observation, by SEM, shows many crystals on the surface and inside the microparticles. A slow-release of the drug in a phosphate buffer pH 7.4 was observed (50% in 60 min and about 70% in 4 h).
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Affiliation(s)
- Stéphane Gibaud
- Laboratoire de Pharmacie Clinique, UPRES EA 2399, Faculté de Pharmacie, 5, rue Albert Lebrun, 54000, Nancy, France.
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Volpe BT, Krebs HI, Hogan N, Edelstein OTR L, Diels C, Aisen M. A novel approach to stroke rehabilitation: robot-aided sensorimotor stimulation. Neurology 2000; 54:1938-44. [PMID: 10822433 DOI: 10.1212/wnl.54.10.1938] [Citation(s) in RCA: 399] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE In patients with stroke, the authors tested whether additional sensorimotor training of the paralyzed or paretic upper limb delivered by a robotic device enhanced motor outcome. METHODS Fifty-six patients with stroke and hemiparesis or hemiplegia received standard poststroke multidisciplinary rehabilitation, and were randomly assigned either to receive robotic training (at least 25 hours) or exposure to the robotic device without training. Outcomes were assessed by the same masked raters, before treatment began and at the end of treatment, with the upper extremity component of the Fugl-Meyer Motor Assessment, the Motor Status score, the Motor Power score, and Functional Independence Measurement. RESULT The robot treatment and control group had comparable clinical characteristics, lesion size, and pretreatment impairment scores. By the end of treatment, the robot-trained group demonstrated improvement in motor outcome for the trained shoulder and elbow (Motor Power score, p < 0.001; Motor Status score, p < 0. 01) that did not generalize to untrained wrist and hand. The robot-treated group also demonstrated significantly improved functional outcome (Functional Independence Measurement-Motor, p < 0. 01). CONCLUSION Robot-delivered quantitative and reproducible sensorimotor training enhanced the motor performance of the exercised shoulder and elbow. The robot-treated group also demonstrated improved functional outcome. When added to standard multidisciplinary rehabilitation, robotics provides novel therapeutic strategies that focus on impairment reduction and improved motor performance.
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Affiliation(s)
- B T Volpe
- Department of Neurology and Neuroscience, Cornell University Medical College, Burke Institute of Medical Research, White Plains, NY 10605, USA.
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Krebs HI, Hogan N, Aisen ML, Volpe BT. Robot-aided neurorehabilitation. IEEE TRANSACTIONS ON REHABILITATION ENGINEERING : A PUBLICATION OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY 1998; 6:75-87. [PMID: 9535526 PMCID: PMC2692541 DOI: 10.1109/86.662623] [Citation(s) in RCA: 490] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Our goal is to apply robotics and automation technology to assist, enhance, quantify, and document neurorehabilitation. This paper reviews a clinical trial involving 20 stroke patients with a prototype robot-aided rehabilitation facility developed at the Massachusetts Institute of Technology, Cambridge, (MIT) and tested at Burke Rehabilitation Hospital, White Plains, NY. It also presents our approach to analyze kinematic data collected in the robot-aided assessment procedure. In particular, we present evidence 1) that robot-aided therapy does not have adverse effects, 2) that patients tolerate the procedure, and 3) that peripheral manipulation of the impaired limb may influence brain recovery. These results are based on standard clinical assessment procedures. We also present one approach using kinematic data in a robot-aided assessment procedure.
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Affiliation(s)
- Hermano Igo Krebs
- Mechanical Engineering Department, Newman Laboratory for Biomechanics and Human Rehabilitation, Massachusetts Institute of Technology, Cambridge, MA 02139 USA (e-mail: )
| | - Neville Hogan
- Mechanical Engineering Department, Newman Laboratory for Biomechanics and Human Rehabilitation, and Brain and Cognitive Sciences Department, the Massachusetts Institute of Technology, Cambridge, MA 02139 USA (e-mail: )
| | - Mindy L. Aisen
- Department of Neurology and Neuroscience, Burke Institute of Medical Research, Cornell University Medical College, White Plains, NY 14850 USA (e-mail: )
| | - Bruce T. Volpe
- Department of Neurology and Neuroscience, Burke Institute of Medical Research, Cornell University Medical College, White Plains, NY 14850 USA (e-mail: )
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Abstract
Hereditary Canine Spinal Muscular Atrophy (HCSMA) is an autosomal dominant disorder of motor neurons that shares features with human motor neuron disease. In animals exhibiting the accelerated phenotype (homozygotes), we demonstrated previously that many motor units exhibit functional deficits that likely reflect underlying deficits in neurotrans-mission. The drug 4-aminopyridine (4AP) blocks voltage-dependent potassium conductances and is capable of increasing neurotransmission by overcoming axonal conduction block or by increasing transmitter release. In this study, we determined whether and to what extent 4AP could enhance muscle force production in HCSMA. Systemic 4AP (1-2 mg/kg) increased nerve-evoked whole muscle twitch force and electromyograms (EMG) to a greater extent in older homozygous animals than in similarly aged, symptomless HCSMA animals or in one younger homozygous animal. The possibility that this difference was caused by the presence of failing motor units in the muscles from homozygotes was tested directly by administering 4AP while recording force produced by failing motor units. The results showed that the twitch force and EMG of failing motor units could be significantly increased by 4AP, whereas no effect was observed in a nonfailing motor unit from a symptomless, aged-matched HCSMA animal. The ability of 4AP to increase force in failing units may be related to the extent of failure. Although 4AP increased peak forces during unit tetanic activation, tetanic force failure was not eliminated. These results demonstrate that the force outputs of failing motor units in HCSMA homozygotes can be increased by 4AP. Possible sites of 4AP action are considered.
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Aisen ML, Sevilla D, Edelstein L, Blass J. A double-blind placebo-controlled study of 3,4-diaminopyridine in amytrophic lateral sclerosis patients on a rehabilitation unit. J Neurol Sci 1996; 138:93-6. [PMID: 8791245 DOI: 10.1016/0022-510x(96)00012-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
3,4-Diaminopyridine (DAP) enhances acetylcholine release from the nerve terminal and improves conduction in demyelinated axons. In this double-blinded placebo controlled cross over study we examined the effects of DAP combined with inpatient rehabilitation in nine patients with disabling motor weakness due to amyotrophic lateral sclerosis (ALS). A single dose of DAP or placebo was increased daily to the maximum (range: 10-80 mg) tolerated dose; after patients were assessed on the first treatment, the alternate drug was given in the same manner. Functional Independence Measurement (FIM), Ashworth, grip strength, limb strength measurements, nerve conduction studies and speech assessments were initiated 1/2 h after receiving the maximum tolerated dose of DAP or placebo. DAP was tolerated in all patients, but limited by gastrointestinal side effects in four patients. The mean peak serum level was 20.11 (S.D. = 5.11) ng/ml, occurring 1.25 (S.D. = 0.56) h after dose. A statistically significant improvement in FIM and speech assessment scores between admission and discharge occurred. However, no significant differences in clinical or electrophysiologic measures were seen between DAP and placebo treatments. This study suggests that intensive inpatient rehabilitation has a role in the management of patients with ALS, but DAP does not diminish motor impairment.
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Affiliation(s)
- M L Aisen
- Burke Rehabilitation Center, White Plains, NY 10605, USA
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