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Shin-Yi Lin C, Howells J, Rutkove S, Nandedkar S, Neuwirth C, Noto YI, Shahrizaila N, Whittaker RG, Bostock H, Burke D, Tankisi H. Neurophysiological and imaging biomarkers of lower motor neuron dysfunction in motor neuron diseases/amyotrophic lateral sclerosis: IFCN handbook chapter. Clin Neurophysiol 2024; 162:91-120. [PMID: 38603949 DOI: 10.1016/j.clinph.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/07/2024] [Accepted: 03/12/2024] [Indexed: 04/13/2024]
Abstract
This chapter discusses comprehensive neurophysiological biomarkers utilised in motor neuron disease (MND) and, in particular, its commonest form, amyotrophic lateral sclerosis (ALS). These encompass the conventional techniques including nerve conduction studies (NCS), needle and high-density surface electromyography (EMG) and H-reflex studies as well as novel techniques. In the last two decades, new methods of assessing the loss of motor units in a muscle have been developed, that are more convenient than earlier methods of motor unit number estimation (MUNE),and may use either electrical stimulation (e.g. MScanFit MUNE) or voluntary activation (MUNIX). Electrical impedance myography (EIM) is another novel approach for the evaluation that relies upon the application and measurement of high-frequency, low-intensity electrical current. Nerve excitability techniques (NET) also provide insights into the function of an axon and reflect the changes in resting membrane potential, ion channel dysfunction and the structural integrity of the axon and myelin sheath. Furthermore, imaging ultrasound techniques as well as magnetic resonance imaging are capable of detecting the constituents of morphological changes in the nerve and muscle. The chapter provides a critical description of the ability of each technique to provide neurophysiological insight into the complex pathophysiology of MND/ALS. However, it is important to recognise the strengths and limitations of each approach in order to clarify utility. These neurophysiological biomarkers have demonstrated reliability, specificity and provide additional information to validate and assess lower motor neuron dysfunction. Their use has expanded the knowledge about MND/ALS and enhanced our understanding of the relationship between motor units, axons, reflexes and other neural circuits in relation to clinical features of patients with MND/ALS at different stages of the disease. Taken together, the ultimate goal is to aid early diagnosis, distinguish potential disease mimics, monitor and stage disease progression, quantify response to treatment and develop potential therapeutic interventions.
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Affiliation(s)
- Cindy Shin-Yi Lin
- Faculty of Medicine and Health, Central Clinical School, Brain and Mind Centre, University of Sydney, Sydney 2006, Australia.
| | - James Howells
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Seward Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sanjeev Nandedkar
- Natus Medical Inc, Middleton, Wisconsin, USA and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christoph Neuwirth
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | - Yu-Ichi Noto
- Department of Neurology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Nortina Shahrizaila
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Roger G Whittaker
- Newcastle University Translational and Clinical Research Institute (NUTCRI), Newcastle University., Newcastle Upon Tyne, United Kingdom
| | - Hugh Bostock
- Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, Queen Square, WC1N 3BG, London, United Kingdom
| | - David Burke
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Evans LJ, O'Brien D, Shaw PJ. Current neuroprotective therapies and future prospects for motor neuron disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:327-384. [PMID: 38802178 DOI: 10.1016/bs.irn.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
Four medications with neuroprotective disease-modifying effects are now in use for motor neuron disease (MND). With FDA approvals for tofersen, relyvrio and edaravone in just the past year, 2022 ended a quarter of a century when riluzole was the sole such drug to offer to patients. The acceleration of approvals may mean we are witnessing the beginning of a step-change in how MND can be treated. Improvements in understanding underlying disease biology has led to more therapies being developed to target specific and multiple disease mechanisms. Consideration for how the pipeline of new therapeutic agents coming through in clinical and preclinical development can be more effectively evaluated with biomarkers, advances in patient stratification and clinical trial design pave the way for more successful translation for this archetypal complex neurodegenerative disease. While it must be cautioned that only slowed rates of progression have so far been demonstrated, pre-empting rapid neurodegeneration by using neurofilament biomarkers to signal when to treat, as is currently being trialled with tofersen, may be more effective for patients with known genetic predisposition to MND. Early intervention with personalized medicines could mean that for some patients at least, in future we may be able to substantially treat what is considered by many to be one of the most distressing diseases in medicine.
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Affiliation(s)
- Laura J Evans
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom
| | - David O'Brien
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom
| | - Pamela J Shaw
- The Sheffield Institute for Translational Neuroscience, and the NIHR Sheffield Biomedical Research Centre, University of Sheffield, Sheffield, United Kingdom.
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Barkhaus PE, Nandedkar SD, de Carvalho M, Swash M, Stålberg EV. Revisiting the compound muscle action potential (CMAP). Clin Neurophysiol Pract 2024; 9:176-200. [PMID: 38807704 PMCID: PMC11131082 DOI: 10.1016/j.cnp.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 04/15/2024] [Accepted: 04/21/2024] [Indexed: 05/30/2024] Open
Abstract
The compound muscle action potential (CMAP) is among the first recorded waveforms in clinical neurography and one of the most common in clinical use. It is derived from the summated muscle fiber action potentials recorded from a surface electrode overlying the studied muscle following stimulation of the relevant motor nerve fibres innervating the muscle. Surface recorded motor unit potentials (SMUPs) are the fundamental units comprising the CMAP. Because it is considered a basic, if not banal signal, what it represents is often underappreciated. In this review we discuss current concepts in the anatomy and physiology of the CMAP. These have evolved with advances in instrumentation and digitization of signals, affecting its quantitation and measurement. It is important to understand the basic technical and biological factors influencing the CMAP. If these influences are not recognized, then a suboptimal recording may result. The object is to obtain a high quality CMAP recording that is reproducible, whether the study is done for clinical or research purposes. The initial sections cover the relevant CMAP anatomy and physiology, followed by how these principles are applied to CMAP changes in neuromuscular disorders. The concluding section is a brief overview of CMAP research where advances in recording systems and computer-based analysis programs have opened new research applications. One such example is motor unit number estimation (MUNE) that is now being used as a surrogate marker in monitoring chronic neurogenic processes such as motor neuron diseases.
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Affiliation(s)
- Paul E. Barkhaus
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
| | - Sanjeev D. Nandedkar
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI USA
- Natus Medical Inc., Hopewell Junction, NY, USA
| | - Mamede de Carvalho
- Instituto de Medicina Molecular and Institute of Physiology, Centro de Estudos Egas Moniz, Faculty of Medicine, University of Lisbon, Portugal
- Department of Neurosciences and Mental Health, CHULN-Hospital de Santa Maria, Lisbon, Portugal
| | - Michael Swash
- Barts and the London School of Medicine, Queen Mary University of London, London UK
| | - Erik V. Stålberg
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
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Vucic S, de Carvalho M, Bashford J, Alix JJP. Contribution of neurophysiology to the diagnosis and monitoring of ALS. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2024; 176:87-118. [PMID: 38802184 DOI: 10.1016/bs.irn.2024.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
This chapter describes the role of neurophysiological techniques in diagnosing and monitoring amyotrophic lateral sclerosis (ALS). Despite many advances, electromyography (EMG) remains a keystone investigation from which to build support for a diagnosis of ALS, demonstrating the pathophysiological processes of motor unit hyperexcitability, denervation and reinnervation. We consider development of the different diagnostic criteria and the role of EMG therein. While not formally recognised by established diagnostic criteria, we discuss the pioneering studies that have demonstrated the diagnostic potential of transcranial magnetic stimulation (TMS) of the motor cortex and highlight the growing evidence for TMS in the diagnostic process. Finally, accurately monitoring disease progression is crucial for the successful implementation of clinical trials. Neurophysiological measures of disease state have been incorporated into clinical trials for over 20 years and we review prominent techniques for assessing disease progression.
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Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, NSW, Australia
| | - Mamede de Carvalho
- Instituto de Medicina Molecular João Lobo Antunes, Centro de Estudos Egas Moniz, Faculty of Medicine, Universidade de Lisboa, Lisboa, Portugal; Department of Neurosciences, CHULN, Centro Académico de Medicina de Lisboa, Lisboa, Portugal
| | - James Bashford
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - James J P Alix
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom.
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Abrahao A, Phung L, Fam D, Escorcio-Bezerra ML, Robinson LR, Jones KE, Zinman L. Motor Unit Number Index of the Upper Trapezius: A Meta-Analysis and Cross-sectional Study of Its Reliability. Can J Neurol Sci 2024; 51:129-133. [PMID: 36751865 DOI: 10.1017/cjn.2023.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Motor unit number index of the upper trapezius (MUNIX-Trapezius) is a candidate biomarker for bulbar lower motor neuron function; however, reliability data is incomplete. To assess MUNIX-Trapezius reliability in controls, we conducted a systematic review, a cross-sectional study (n = 20), and a meta-analysis. We demonstrated a high inter- and intra-rater intraclass correlation (0.86 and 0.94, respectively), indicating that MUNIX-Trapezius is reliable with between-study variability moderated by age and MUNIX technique. With further validation, this measure can serve as a disease monitoring and response biomarker of bulbar function in the therapeutic development for amyotrophic lateral sclerosis.
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Affiliation(s)
- Agessandro Abrahao
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Liane Phung
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - David Fam
- St. Joseph's Health Centre Toronto, United Health, Toronto, Ontario, Canada
| | | | - Lawrence R Robinson
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Kelvin E Jones
- Faculty of Kinesiology, Sport and Recreation, University of Alberta, Edmonton, Alberta, Canada
| | - Lorne Zinman
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, University of Toronto, Toronto, Ontario, Canada
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Sleutjes BTHM, Stikvoort García DJL, van Doorn PA, Goedee HS, van den Berg LH. Simulating progressive motor neuron degeneration and collateral reinnervation in motor neuron diseases using a dynamic muscle model based on human single motor unit recordings. J Neural Eng 2023; 20:056039. [PMID: 37774693 DOI: 10.1088/1741-2552/acfe9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 09/29/2023] [Indexed: 10/01/2023]
Abstract
Objective.To simulate progressive motor neuron loss and collateral reinnervation in motor neuron diseases (MNDs) by developing a dynamic muscle model based on human single motor unit (MU) surface-electromyography (EMG) recordings.Approach.Single MU potentials recorded with high-density surface-EMG from thenar muscles formed the basic building blocks of the model. From the baseline MU pool innervating a muscle, progressive MU loss was simulated by removal of MUs, one-by-one. These removed MUs underwent collateral reinnervation with scenarios varying from 0% to 100%. These scenarios were based on a geometric variable, reflecting the overlap in MU territories using the spatiotemporal profiles of single MUs and a variable reflecting the efficacy of the reinnervation process. For validation, we tailored the model to generate compound muscle action potential (CMAP) scans, which is a promising surface-EMG method for monitoring MND patients. Selected scenarios for reinnervation that matched observed MU enlargements were used to validate the model by comparing markers (including the maximum CMAP and a motor unit number estimate (MUNE)) derived from simulated and recorded CMAP scans in a cohort of 49 MND patients and 22 age-matched healthy controls.Main results.The maximum CMAP at baseline was 8.3 mV (5th-95th percentile: 4.6 mV-11.8 mV). Phase cancellation caused an amplitude drop of 38.9% (5th-95th percentile, 33.0%-45.7%). To match observations, the geometric variable had to be set at 40% and the efficacy variable at 60%-70%. The Δ maximum CMAP between recorded and simulated CMAP scans as a function of fitted MUNE was -0.4 mV (5th-95th percentile = -4.0 - +2.4 mV).Significance.The dynamic muscle model could be used as a platform to train personnel in applying surface-EMG methods prior to their use in clinical care and trials. Moreover, the model may pave the way to compare biomarkers more efficiently, without directly posing unnecessary burden on patients.
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Affiliation(s)
- Boudewijn T H M Sleutjes
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Leonard H van den Berg
- Department of Neurology, Brain Center Utrecht, University Medical Center Utrecht, Utrecht, The Netherlands
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Abstract
Although the past two decades have produced exciting discoveries in the genetics and pathology of amyotrophic lateral sclerosis (ALS), progress in developing an effective therapy remains slow. This review summarizes the critical discoveries and outlines the advances in disease characterization, diagnosis, imaging, and biomarkers, along with the current status of approaches to ALS care and treatment. Additional knowledge of the factors driving disease progression and heterogeneity will hopefully soon transform the care for patients with ALS into an individualized, multi-prong approach able to prevent disease progression sufficiently to allow for a dignified life with limited disability.
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Affiliation(s)
- Hristelina Ilieva
- Jefferson Weinberg ALS Center, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Justin Kwan
- National Institute of Neurological Disorders and Stroke, National Institute of Health, Bethesda, MD, USA
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Xue S, Gao F, Wu X, Xu Q, Weng X, Zhang Q. MUNIX repeatability evaluation method based on FastICA demixing. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:16362-16382. [PMID: 37920016 DOI: 10.3934/mbe.2023730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
To enhance the reproducibility of motor unit number index (MUNIX) for evaluating neurological disease progression, this paper proposes a negative entropy-based fast independent component analysis (FastICA) demixing method to assess MUNIX reproducibility in the presence of inter-channel mixing of electromyography (EMG) signals acquired by high-density electrodes. First, composite surface EMG (sEMG) signals were obtained using high-density surface electrodes. Second, the FastICA algorithm based on negative entropy was employed to determine the orthogonal projection matrix that minimizes the negative entropy of the projected signal and effectively separates mixed sEMG signals. Finally, the proposed experimental approach was validated by introducing an interrelationship criterion to quantify independence between adjacent channel EMG signals, measuring MUNIX repeatability using coefficient of variation (CV), and determining motor unit number and size through MUNIX. Results analysis shows that the inclusion of the full (128) channel sEMG information leads to a reduction in CV value by $1.5 \pm 0.1$ and a linear decline in CV value with an increase in the number of channels. The correlation between adjacent channels in participants decreases by $0.12 \pm 0.05$ as the number of channels gradually increases. The results demonstrate a significant reduction in the number of interrelationships between sEMG signals following negative entropy-based FastICA processing, compared to the mixed sEMG signals. Moreover, this decrease in interrelationships becomes more pronounced with an increasing number of channels. Additionally, the CV of MUNIX gradually decreases with an increase in the number of channels, thereby optimizing the issue of abnormal MUNIX repeatability patterns and further enhancing the reproducibility of MUNIX based on high-density surface EMG signals.
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Affiliation(s)
- Suqi Xue
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Farong Gao
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Xudong Wu
- Department of Orthopedics, Zhoushan Hospital of Traditional Chinese Medicine, Zhoushan 316000, China
| | - Qun Xu
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Xuecheng Weng
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Qizhong Zhang
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
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Sørensen DM, Bostock H, Abrahao A, Alaamel A, Alaydin HC, Ballegaard M, Boran E, Cengiz B, de Carvalho M, Dunker Ø, Fuglsang-Frederiksen A, Graffe CC, Jones KE, Kallio M, Kalra S, Krarup C, Krøigård T, Liguori R, Lupescu T, Maitland S, Matamala JM, Moldovan M, Moreno-Roco J, Nilsen KB, Phung L, Santos MO, Themistocleous AC, Uysal H, Vacchiano V, Whittaker RG, Zinman L, Tankisi H. Estimating motor unit numbers from a CMAP scan: Repeatability study on three muscles at 15 centres. Clin Neurophysiol 2023; 151:92-99. [PMID: 37236129 DOI: 10.1016/j.clinph.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/16/2023] [Accepted: 04/15/2023] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To assess the repeatability and suitability for multicentre studies of MScanFit motor unit number estimation (MUNE), which involves modelling compound muscle action potential (CMAP) scans. METHODS Fifteen groups in 9 countries recorded CMAP scans twice, 1-2 weeks apart in healthy subjects from abductor pollicis brevis (APB), abductor digiti minimi (ADM) and tibialis anterior (TA) muscles. The original MScanFit program (MScanFit-1) was compared with a revised version (MScanFit-2), designed to accommodate different muscles and recording conditions by setting the minimal motor unit size as a function of maximum CMAP. RESULTS Complete sets of 6 recordings were obtained from 148 subjects. CMAP amplitudes differed significantly between centres for all muscles, and the same was true for MScanFit-1 MUNE. With MScanFit-2, MUNE differed less between centres but remained significantly different for APB. Coefficients of variation between repeats were 18.0% for ADM, 16.8% for APB, and 12.1% for TA. CONCLUSIONS It is recommended for multicentre studies to use MScanFit-2 for analysis. TA provided the least variable MUNE values between subjects and the most repeatable within subjects. SIGNIFICANCE MScanFit was primarily devised to model the discontinuities in CMAP scans in patients and is less suitable for healthy subjects with smooth scans.
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Affiliation(s)
- D M Sørensen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark
| | - H Bostock
- UCL Queen Square Institute of Neurology, Queen Square, London, United Kingdom
| | - A Abrahao
- Department of Medicine, University of Toronto, Toronto, Canada
| | - A Alaamel
- Department of Neurology, Akdeniz University Hospital, Antalya, Turkey
| | - H C Alaydin
- Department of Neurology, Gazi University, Ankara, Turkey
| | - M Ballegaard
- Department of Clinical Neurology, Zealand University Hospital, Roskilde, Denmark
| | - E Boran
- Department of Neurology, Gazi University, Ankara, Turkey
| | - B Cengiz
- Department of Neurology, Gazi University, Ankara, Turkey
| | - M de Carvalho
- Faculty of Medicine, iMM, Centro de Estudos Egas Moniz, Universidade de Lisboa, Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - Ø Dunker
- Department of Neurology and Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Norway
| | - A Fuglsang-Frederiksen
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark; Department of Clinical Institute, Aarhus University, Aarhus, Denmark
| | - C C Graffe
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - K E Jones
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - M Kallio
- Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - S Kalra
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - C Krarup
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - T Krøigård
- Department of Neurology, Odense University Hospital, Denmark
| | - R Liguori
- Dipertimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - T Lupescu
- Department of Neurology, Agrippa Ionescu Hospital, Bucharest, Romania
| | - S Maitland
- Translational and Clinical Research Institute, Newcastle University, United Kingdom
| | - J M Matamala
- Translational Neurology and Neurophysiology Lab, Department of Neurological Sciences and Biomedical Neuroscience Institute, University of Chile, Santiago, Chile
| | - M Moldovan
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - J Moreno-Roco
- Translational Neurology and Neurophysiology Lab, Department of Neurological Sciences and Biomedical Neuroscience Institute, University of Chile, Santiago, Chile
| | - K B Nilsen
- Department of Neurology and Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Norway
| | - L Phung
- Department of Medicine, University of Toronto, Toronto, Canada
| | - M O Santos
- Faculty of Medicine, iMM, Centro de Estudos Egas Moniz, Universidade de Lisboa, Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - A C Themistocleous
- Nuffield Department of Clinical Neurosciences University of Oxford, Oxford, United Kingdom
| | - H Uysal
- Department of Medicine, University of Toronto, Toronto, Canada
| | - V Vacchiano
- Dipertimento di Scienze Biomediche e Neuromotorie, Università di Bologna, Bologna, Italy
| | - R G Whittaker
- Translational and Clinical Research Institute, Newcastle University, United Kingdom
| | - L Zinman
- UCL Queen Square Institute of Neurology, Queen Square, London, United Kingdom
| | - H Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark; Department of Clinical Institute, Aarhus University, Aarhus, Denmark.
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Vucic S, Menon P, Huynh W, Mahoney C, Ho KS, Hartford A, Rynders A, Evan J, Evan J, Ligozio S, Glanzman R, Hotchkin MT, Kiernan MC. Efficacy and safety of CNM-Au8 in amyotrophic lateral sclerosis (RESCUE-ALS study): a phase 2, randomised, double-blind, placebo-controlled trial and open label extension. EClinicalMedicine 2023; 60:102036. [PMID: 37396808 PMCID: PMC10314176 DOI: 10.1016/j.eclinm.2023.102036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/17/2023] [Accepted: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
Background CNM-Au8® is a catalytically-active gold nanocrystal neuroprotective agent that enhances intracellular energy metabolism and reduces oxidative stress. The phase 2, randomised, double-blind, placebo-controlled trial and open label extension RESCUE-ALS trial evaluated the efficacy and safety of CNM-Au8 for treatment of amyotrophic lateral sclerosis (ALS). Methods RESCUE-ALS and its long-term open label extension (OLE) were conducted at two multidisciplinary ALS clinics located in Sydney, Australia: (i) the Brain and Mind Centre and (ii) Westmead Hospital. The double-blind portion of RESCUE-ALS was conducted from January 16, 2020 (baseline visit, first-patient first-visit (FPFV)) through July 13, 2021 (double-blind period, last-patient last-visit (LPLV)). Participants (N = 45) were randomised 1:1 to receive 30 mg of CNM-Au8 or matching placebo daily over 36 weeks in addition to background standard of care, riluzole. The primary outcome was mean percent change in summed motor unit number index (MUNIX), a sensitive neurophysiological biomarker of lower motor neuron function. Change in total (or summated) MUNIX score and change in forced vital capacity (FVC) were secondary outcome measures. ALS disease progression events, ALS Functional Rating Scale (ALSFRS-R) change, change in quality of life (ALSSQOL-SF) were assessed as exploratory outcome measures. Long-term survival evaluated vital status of original active versus placebo randomisation for all participants through at least 12 months following last-patient last-visit (LPLV) of the double-blind period. RESCUE-ALS and the open label study are registered in clinicaltrials.gov with registration numbers NCT04098406 and NCT05299658, respectively. Findings In the intention-to-treat (ITT) population, there was no significant difference in the summated MUNIX score percent change (LS mean difference: 7.7%, 95% CI: -11.9 to 27.3%, p = 0.43), total MUNIX score change (18.8, 95% CI: -56.4 to 94.0), or FVC change (LS mean difference: 3.6, 95% CI: -12.4 to 19.7) between the active and placebo treated groups at week 36. In contrast, survival analyses through 12-month LPLV demonstrated a 60% reduction in all-cause mortality with CNM-Au8 treatment [hazard ratio = 0.408 (95% Wald CI: 0.166 to 1.001, log-rank p = 0.0429). 36 participants entered the open label extension (OLE), and those initially randomised to CNM-Au8 exhibited a slower rate of disease progression, as measured by time to the occurrence of death, tracheostomy, initiation of non-invasive ventilatory support, or gastrostomy tube placement. CNM-Au8 was well-tolerated, and no safety signals were observed. Interpretation CNM-Au8, in combination with riluzole, was well-tolerated in ALS with no identified safety signals. While the primary and secondary outcomes of this trial were not significant, the clinically meaningful exploratory results support further investigation of CNM-Au8 in ALS. Funding The RESCUE-ALS was substantially funded by a grant from FightMND. Additional funding was provided by Clene Australia Pty Ltd.
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Affiliation(s)
- Steve Vucic
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - Parvathi Menon
- Brain and Nerve Research Centre, Concord Clinical School and Department of Neurology, Concord Repatriation General Hospital, The University of Sydney, Sydney, Australia
| | - William Huynh
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Colin Mahoney
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Karen S. Ho
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | - Jacob Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | - Jeremy Evan
- Clene Nanomedicine, Inc., Salt Lake City, UT, USA
| | | | | | | | - Matthew C. Kiernan
- Brain and Mind Centre, University of Sydney, and Department of Neurology, Royal Prince Alfred Hospital, Sydney, Australia
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Motor unit number index (MUNIX) loss of 50% occurs in half the time of 50% functional loss according to the D50 disease progression model of ALS. Sci Rep 2023; 13:3981. [PMID: 36894607 PMCID: PMC9998642 DOI: 10.1038/s41598-023-30871-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/02/2023] [Indexed: 03/11/2023] Open
Abstract
Capturing disease progression in amyotrophic lateral sclerosis (ALS) is challenging and refinement of progression markers is urgently needed. This study introduces new motor unit number index (MUNIX), motor unit size index (MUSIX) and compound muscle action potential (CMAP) parameters called M50, MUSIX200 and CMAP50. M50 and CMAP50 indicate the time in months from symptom onset an ALS patient needs to lose 50% of MUNIX or CMAP in relation to the mean values of controls. MUSIX200 represents the time in months until doubling of the mean MUSIX of controls. We used MUNIX parameters of Musculi abductor pollicis brevis (APB), abductor digiti minimi (ADM) and tibialis anterior (TA) of 222 ALS patients. Embedded in the D50 disease progression model, disease aggressiveness and accumulation were analyzed separately. M50, CMAP50 and MUSIX200 significantly differed among disease aggressiveness subgroups (p < 0.001) regardless of disease accumulation. ALS patients with a low M50 had a significantly shorter survival compared to high M50 (median 32 versus 74 months). M50 preceded the loss of global function (median of about 14 months). M50, CMAP50 and MUSIX200 characterize the disease course in ALS in a new way and may be applied as early measures of disease progression.
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Xu Q, Xue S, Gao F, Wu Q, Zhang Q. Evaluation method of motor unit number index based on optimal muscle strength combination. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:3854-3872. [PMID: 36899608 DOI: 10.3934/mbe.2023181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Repeatability is an important attribute of motor unit number index (MUNIX) technology. This paper proposes an optimal contraction force combination for MUNIX calculation in an effort to improve the repeatability of this technology. In this study, the surface electromyography (EMG) signals of the biceps brachii muscle of eight healthy subjects were initially recorded with high-density surface electrodes, and the contraction strength was the maximum voluntary contraction force of nine progressive levels. Then, by traversing and comparing the repeatability of MUNIX under various combinations of contraction force, the optimal combination of muscle strength is determined. Finally, calculate MUNIX using the high-density optimal muscle strength weighted average method. The correlation coefficient and the coefficient of variation are utilized to assess repeatability. The results show that when the muscle strength combination is 10, 20, 50 and 70% of the maximum voluntary contraction force, the repeatability of MUNIX is greatest, and the correlation between MUNIX calculated using this combination of muscle strength and conventional methods is high (PCC > 0.99), the repeatability of the MUNIX method improved by 11.5-23.8%. The results indicate that the repeatability of MUNIX differs for various combinations of muscle strength and that MUNIX, which is measured with a smaller number and lower-level contractility, has greater repeatability.
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Affiliation(s)
- Qun Xu
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Suqi Xue
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Farong Gao
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Qiuxuan Wu
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
| | - Qizhong Zhang
- School of Artificial Intelligence, Hangzhou Dianzi University, Hangzhou 310018, China
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13
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Abstract
The objective was to use bibliometric analysis to create an infographic of motor unit number estimation methods over the past 50 years. The original method was published in 1971, but secondary and tertiary waves of research using alternative methods occurred in the early 2000s and a decade later. A metric of influence was used to determine if different methods had clear peaks of use over the past 50 years. While the original method continues to register influence, the MUNIX method introduced in 2004 stands out as the most influential method to estimate the innervation status of skeletal muscles.
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Sandberg A. Motor unit properties do not correlate between MUNIX and needle EMG in remote polio in the biceps brachii muscle. Clin Neurophysiol Pract 2022; 8:24-31. [PMID: 36632370 PMCID: PMC9826944 DOI: 10.1016/j.cnp.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/07/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Objective To compare the utility of MUNIX (motor unit number index) with needle EMG in characterizing motor unit (MU) properties in the biceps brachii (BB) muscle in subjects with remote polio. Methods Thirty subjects suffering from remote polio were investigated with MUNIX and needle EMG, all with Macro EMG and 16 of these subjects with concentric needle EMG. Results Both MUNIX and the needle EMG methods showed abnormal results. Fiber density (FD) was the most sensitive parameter for showing signs of reinnervation. At a group level, the methods showed neurogenic findings, but there was no correlation between the results of the MUNIX and needle EMG investigations. Conclusions Both MUNIX and needle EMG are valuable methods for measuring neurogenic involvement in the BB muscle. However, there was a lack of correlation between the MUNIX and needle EMG findings. The cause for this missing correlation may be multifactorial as there are several differences between the methods. Significance The reason for the lack of correlation between the MUNIX and needle EMG results is discussed. By combining the needle and surface recorded methods one can obtain more information on the denervation and reinnervation process compared to using just one of the methods alone.
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Feldman EL, Goutman SA, Petri S, Mazzini L, Savelieff MG, Shaw PJ, Sobue G. Amyotrophic lateral sclerosis. Lancet 2022; 400:1363-1380. [PMID: 36116464 PMCID: PMC10089700 DOI: 10.1016/s0140-6736(22)01272-7] [Citation(s) in RCA: 210] [Impact Index Per Article: 105.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/24/2022] [Accepted: 06/23/2022] [Indexed: 01/07/2023]
Abstract
Amyotrophic lateral sclerosis is a fatal CNS neurodegenerative disease. Despite intensive research, current management of amyotrophic lateral sclerosis remains suboptimal from diagnosis to prognosis. Recognition of the phenotypic heterogeneity of amyotrophic lateral sclerosis, global CNS dysfunction, genetic architecture, and development of novel diagnostic criteria is clarifying the spectrum of clinical presentation and facilitating diagnosis. Insights into the pathophysiology of amyotrophic lateral sclerosis, identification of disease biomarkers and modifiable risks, along with new predictive models, scales, and scoring systems, and a clinical trial pipeline of mechanism-based therapies, are changing the prognostic landscape. Although most recent advances have yet to translate into patient benefit, the idea of amyotrophic lateral sclerosis as a complex syndrome is already having tangible effects in the clinic. This Seminar will outline these insights and discuss the status of the management of amyotrophic lateral sclerosis for the general neurologist, along with future prospects that could improve care and outcomes for patients with amyotrophic lateral sclerosis.
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Affiliation(s)
- Eva L Feldman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Stephen A Goutman
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, Hannover, Germany
| | - Letizia Mazzini
- ALS Centre, Azienda Ospedaliero-Universitaria Maggiore della Carità, Novara, Italy; Department of Neurology, University of Piemonte Orientale, Novara, Italy
| | - Masha G Savelieff
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, UK
| | - Gen Sobue
- Department of Neurology, Aichi Medical University, Nagakute, Aichi, Japan
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16
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Motor unit number index (MUNIX) in the D50 disease progression model reflects disease accumulation independently of disease aggressiveness in ALS. Sci Rep 2022; 12:15997. [PMID: 36163485 PMCID: PMC9512899 DOI: 10.1038/s41598-022-19911-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022] Open
Abstract
The neurophysiological technique motor unit number index (MUNIX) is increasingly used in clinical trials to measure loss of motor units. However, the heterogeneous disease course in amyotrophic lateral sclerosis (ALS) obfuscates robust correlations between clinical status and electrophysiological assessments. To address this heterogeneity, MUNIX was applied in the D50 disease progression model by analyzing disease aggressiveness (D50) and accumulation (rD50 phase) in ALS separately. 237 ALS patients, 45 controls and 22 ALS-Mimics received MUNIX of abductor pollicis brevis (APB), abductor digiti minimi (ADM) and tibialis anterior (TA) muscles. MUNIX significantly differed between controls and ALS patients and between ALS-Mimics and controls. Within the ALS cohort, significant differences between Phase I and II revealed in MUNIX, compound muscle action potential (CMAP) and motor unit size index (MUSIX) of APB as well as in MUNIX and CMAP of TA. For the ADM, significant differences occurred later in CMAP and MUNIX between Phase II and III/IV. In contrast, there was no significant association between disease aggressiveness and MUNIX. In application of the D50 disease progression model, MUNIX can demonstrate disease accumulation already in early Phase I and evaluate effects of therapeutic interventions in future therapeutic trials independent of individual disease aggressiveness.
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Fournier CN. Considerations for Amyotrophic Lateral Sclerosis (ALS) Clinical Trial Design. Neurotherapeutics 2022; 19:1180-1192. [PMID: 35819713 PMCID: PMC9275386 DOI: 10.1007/s13311-022-01271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/20/2022] Open
Abstract
Thoughtful clinical trial design is critical for efficient therapeutic development, particularly in the field of amyotrophic lateral sclerosis (ALS), where trials often aim to detect modest treatment effects among a population with heterogeneous disease progression. Appropriate outcome measure selection is necessary for trials to provide decisive and informative results. Investigators must consider the outcome measure's reliability, responsiveness to detect change when change has actually occurred, clinical relevance, and psychometric performance. ALS clinical trials can also be performed more efficiently by utilizing statistical enrichment techniques. Innovations in ALS prediction models allow for selection of participants with less heterogeneity in disease progression rates without requiring a lead-in period, or participants can be stratified according to predicted progression. Statistical enrichment can reduce the needed sample size and improve study power, but investigators must find a balance between optimizing statistical efficiency and retaining generalizability of study findings to the broader ALS population. Additional progress is still needed for biomarker development and validation to confirm target engagement in ALS treatment trials. Selection of an appropriate biofluid biomarker depends on the treatment mechanism of interest, and biomarker studies should be incorporated into early phase trials. Inclusion of patients with ALS as advisors and advocates can strengthen clinical trial design and study retention, but more engagement efforts are needed to improve diversity and equity in ALS research studies. Another challenge for ALS therapeutic development is identifying ways to respect patient autonomy and improve access to experimental treatment, something that is strongly desired by many patients with ALS and ALS advocacy organizations. Expanded access programs that run concurrently to well-designed and adequately powered randomized controlled trials may provide an opportunity to broaden access to promising therapeutics without compromising scientific integrity or rushing regulatory approval of therapies without adequate proof of efficacy.
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Affiliation(s)
- Christina N Fournier
- Department of Neurology, Emory University, Atlanta, GA, USA.
- Department of Veterans Affairs, Atlanta, GA, USA.
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18
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Martínez-Payá J, Ríos-Díaz J, del Baño-Aledo M, Hervás D, Tembl-Ferrairó J, Sevilla-Mantecón T, Vázquez-Costa J. The cross-sectional area of the median nerve: An independent prognostic biomarker in amyotrophic lateral sclerosis. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Ahmed N, Baker MR, Bashford J. The landscape of neurophysiological outcome measures in ALS interventional trials: A systematic review. Clin Neurophysiol 2022; 137:132-141. [PMID: 35313253 PMCID: PMC10166714 DOI: 10.1016/j.clinph.2022.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We collated all interventional clinical trials in amyotrophic lateral sclerosis (ALS), which utilised at least one neurophysiological technique as a primary or secondary outcome measure. By identifying the strengths and limitations of these studies, we aim to guide study design in future trials. METHODS We conducted and reported this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight databases were searched from inception. In total, 703 studies were retrieved for screening and eligibility assessment. RESULTS Dating back to 1986, 32 eligible interventional clinical trials were identified, recruiting a median of 30 patients per completed trial. The most widely employed neurophysiological techniques were electromyography, motor unit number estimation (including motor unit number index), neurophysiological index and transcranial magnetic stimulation (including resting motor threshold and short-interval intracortical inhibition). Almost 40% of trials reported a positive outcome with respect to at least one neurophysiological measure. The interventions targeted either ion channels, immune mechanisms or neuronal metabolic pathways. CONCLUSIONS Neurophysiology offers many promising biomarkers that can be utilised as outcome measures in interventional clinical trials in ALS. When selecting the most appropriate technique, key considerations include methodological standardisation, target engagement and logistical burden. SIGNIFICANCE Future trial design in ALS would benefit from a standardised, updated and easily accessible repository of neurophysiological outcome measures.
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Affiliation(s)
- N Ahmed
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, UK
| | - M R Baker
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - J Bashford
- UK Dementia Research Institute, Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
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Sørensen DM, Bostock H, Ballegaard M, Fuglsang-Frederiksen A, Graffe CC, Grötting A, Jones K, Kallio M, Krarup C, Krøigård T, Lupescu T, Maitland S, Moldovan M, Nilsen KB, Pugdahl K, Santos MO, Themistocleous AC, Zlateva SS, Ööpik M, Tankisi H. Assessing inter-rater reproducibility in MScanFit MUNE in a 6-subject, 12-rater "Round Robin" setup. Neurophysiol Clin 2021; 52:157-169. [PMID: 34906430 DOI: 10.1016/j.neucli.2021.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/20/2021] [Accepted: 11/20/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To assess the inter-rater reliability of MScanFit MUNE using a "Round Robin" research design. METHODS Twelve raters from different centres examined six healthy study participants over two days. Median, ulnar and common peroneal nerves were stimulated, and compound muscle action potential (CMAP)-scans were recorded from abductor pollicis brevis (APB), abductor digiti minimi (ADM) and anterior tibial (TA) muscles respectively. From this we calculated the Motor Unit Number Estimation (MUNE) and "A50", a motor unit size parameter. As statistical analysis we used the measures Limits of Agreement (LOA) and Coefficient of Variation (COV). Study participants scored their perception of pain from the examinations on a rating scale from 0 (no pain) to 10 (unbearable pain). RESULTS Before this study, 41.6% of the raters had performed MScanFit less than five times. The mean MUNE-values were: 99.6 (APB), 131.4 (ADM) and 126.2 (TA), with LOA: 19.5 (APB), 29.8 (ADM) and 20.7 (TA), and COV: 13.4 (APB), 6.3 (ADM) and 5.6 (TA). MUNE-values correlated to CMAP max amplitudes (R2-values were: 0.463 (APB) (p<0.001), 0.421 (ADM) (p<0.001) and 0.645 (TA) (p<0.001)). The average perception of pain was 4. DISCUSSION MScanFit indicates a high level of inter-rater reliability, even with only limited rater experience and is overall reasonably well tolerated by patients. These results may indicate MScanFit as a reliable MUNE method with potential as a biomarker in drug trials.
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Affiliation(s)
| | - Hugh Bostock
- Insitute of Neurology, Queen Square House, London, United Kingdom
| | - Martin Ballegaard
- Deparment of Clinical Neurology, Zealand University Hospital, Roskilde, Denmark
| | | | | | - Arnstein Grötting
- Department of Clinical Neurophysiology, St. Olav Hospital, Trondheim, Norway
| | - Kelvin Jones
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, Canada
| | - Mika Kallio
- Department of Clinical Neurophysiology, Oulu University Hospital, Oulu, Finland
| | - Christian Krarup
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Krøigård
- Department of Neurology, Odense University Hospital, Denmark
| | - Tudor Lupescu
- Department of Neurology, Agrippa Ionescu Hospital, Bucharest, Romania
| | - Stuart Maitland
- Newcastle Biomedical Research Centre, Newcastle upon Tyne, United Kingdom
| | - Mihai Moldovan
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Kirsten Pugdahl
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark
| | - Miguel Oliveira Santos
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | | | | | - Merle Ööpik
- Deparment of Clinical Neurology, Zealand University Hospital, Roskilde, Denmark
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Denmark.
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Sleutjes BTHM, Bystrup Jacobsen A, Tankisi H, Gorkem Sirin N, Emre Oge A, Henderson RD, van Doorn PA, van den Berg LH, van Eijk RPA. Advancing disease monitoring of amyotrophic lateral sclerosis with the compound muscle action potential scan. Clin Neurophysiol 2021; 132:3152-3159. [PMID: 34749234 DOI: 10.1016/j.clinph.2021.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/20/2021] [Accepted: 09/15/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine which compound muscle action potential (CMAP) scan-derived electrophysiological markers are most sensitive for monitoring disease progression in amyotrophic lateral sclerosis (ALS), and whether they hold value for clinical trials. METHODS We used four independent patient cohorts to assess longitudinal patterns of a comprehensive set of electrophysiological markers including their association with the ALS functional rating scale (ALSFRS-R). Results were translated to trial sample size requirements. RESULTS In 65 patients, 225 thenar CMAP scan recordings were obtained. Electrophysiological markers showed extensive variation in their longitudinal trajectories. Expressed as standard deviations per month, motor unit number estimation (MUNE) values declined by 0.09 (CI 0.07-0.12), D50, a measure that quantifies CMAP scan discontinuities, declined by 0.09 (CI 0.06-0.13) and maximum CMAP by 0.05 (CI 0.03-0.08). ALSFRS-R declined fastest (0.12, CI 0.08 - 0.15), however the between-patient variability was larger compared to electrophysiological markers, resulting in larger sample sizes. MUNE reduced the sample size by 19.1% (n = 388 vs n = 314) for a 6-month study compared to the ALSFRS-R. CONCLUSIONS CMAP scan-derived markers show promise in monitoring disease progression in ALS patients, where MUNE may be its most suitable derivate. SIGNIFICANCE MUNE may increase clinical trial efficiency compared to clinical endpoints.
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Affiliation(s)
- Boudewijn T H M Sleutjes
- Department of Neurology, Brain Centre Utrecht, Utrecht, the Netherlands; Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
| | | | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - N Gorkem Sirin
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - A Emre Oge
- Department of Neurology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Robert D Henderson
- Department of Neurology, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Pieter A van Doorn
- Department of Neurology, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Ruben P A van Eijk
- Department of Neurology, Brain Centre Utrecht, Utrecht, the Netherlands; Biostatistics and Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
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22
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Chan Y, Alix JJP, Neuwirth C, Barkhaus PE, Castro J, Jenkins TM, McDermott CJ, Shaw PJ, de Carvalho M, Nandedkar S, Stålberg E, Weber M. Reinnervation as measured by the motor unit size index is associated with preservation of muscle strength in amyotrophic lateral sclerosis, but not all muscles reinnervate. Muscle Nerve 2021; 65:203-210. [PMID: 34687220 DOI: 10.1002/mus.27444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION/AIMS The motor unit size index (MUSIX) may provide insight into reinnervation patterns in diseases such as amyotrophic lateral sclerosis (ALS). However, it is not known whether MUSIX detects clinically relevant changes in reinnervation, or if all muscles manifest changes in MUSIX in response to reinnervation after motor unit loss. METHODS Fifty-seven patients with ALS were assessed at 3-month intervals for 12 months in four centers. Muscles examined were abductor pollicis brevis, abductor digiti minimi, biceps brachii, and tibialis anterior. Results were split into two groups: muscles with increases in MUSIX and those without increases. Longitudinal changes in MUSIX, motor unit number index (MUNIX), compound muscle action potential amplitude, and Medical Research Council strength score were investigated. RESULTS One hundred thirty-three muscles were examined. Fifty-nine percent of the muscles exhibited an increase in MUSIX during the study. Muscles with MUSIX increases lost more motor units (58% decline in MUNIX at 12 months, P < .001) than muscles that did not increase MUSIX (34.6% decline in MUNIX at 12 months, P < .001). However, longitudinal changes in muscle strength were similar. When motor unit loss was similar, the absence of a MUSIX increase was associated with a significantly greater loss of muscle strength (P = .002). DISCUSSION MUSIX increases are associated with greater motor unit loss but relative preservation of muscle strength. Thus, MUSIX appears to be measuring a clinically relevant response that can provide a quantitative outcome measure of reinnervation in clinical trials. Furthermore, MUSIX suggests that reinnervation may play a major role in determining the progression of weakness.
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Affiliation(s)
- Young Chan
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - James J P Alix
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Christoph Neuwirth
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | | | - José Castro
- Department of Neurosciences, Centro Hospitalar Lisboa Norte-Hospital de Santa Maria, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Thomas M Jenkins
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | | | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Mamede de Carvalho
- Department of Neurosciences, Centro Hospitalar Lisboa Norte-Hospital de Santa Maria, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | | | - Erik Stålberg
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Uppsala, Sweden
| | - Markus Weber
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
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23
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Cai H, Kroll M, Annaswamy T. Motor Unit Number Index in Evaluating Patients With Lumbar Spinal Stenosis. Am J Phys Med Rehabil 2021; 100:966-971. [PMID: 33433110 DOI: 10.1097/phm.0000000000001681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Motor unit number index is a quantitative electrophysiological measure that provides an index of the number of motor neurons supplying a muscle. The aim of this exploratory study was to assess the utility of motor unit number index in the evaluation of patients with lumbar spinal stenosis. DESIGN Participants were assigned to three groups: clinical and radiological lumbar stenosis (lumbar spinal stenosis with neurogenic intermittent claudication), group A; radiological lumbar spinal stenosis without neurogenic intermittent claudication, group B; and a control group, group C. Patients self-rated their pain and functional disability using the numerical rating scale and a series of functional questionnaires. An electromyographer performed nerve conduction tests, electromyography, and motor unit number index testing. RESULTS Seventeen patients completed the study. There were 9, 5, and 3 patients in groups A, B, and C, respectively. There were no discernable differences in motor unit number index values of any individual muscle or combined motor unit number index score between the three groups. Motor unit number index values did not correlate to pain/functional measures. CONCLUSIONS In this exploratory study, motor unit number index did not demonstrate discriminatory ability between patients with lumbar spinal stenosis and was not correlated with pain and functional measures. Further study is needed to explore motor unit number index's role in longitudinal evaluation of patients with the clinical syndrome of lumbar spinal stenosis.
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Affiliation(s)
- Haibi Cai
- From the Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, Texas (HC); and Physical Medicine and Rehabilitation Service, Dallas VA Medical Center, North Texas Health Care System, Dallas, Texas (MK, TA)
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Pino MG, Rich KA, Kolb SJ. Update on Biomarkers in Spinal Muscular Atrophy. Biomark Insights 2021; 16:11772719211035643. [PMID: 34421296 PMCID: PMC8371741 DOI: 10.1177/11772719211035643] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/07/2021] [Indexed: 11/25/2022] Open
Abstract
The availability of disease modifying therapies for spinal muscular atrophy (SMA) has created an urgent need to identify clinically meaningful biomarkers. Biomarkers present a means to measure and evaluate neurological disease across time. Changes in biomarkers provide insight into disease progression and may reveal biologic, physiologic, or pharmacologic phenomena occurring prior to clinical detection. Efforts to identify biomarkers for SMA, a genetic motor neuron disease characterized by motor neuron degeneration and weakness, have culminated in a number of putative molecular and physiologic markers that evaluate biological media (eg, blood and cerebrospinal fluid [CSF]) or nervous system function. Such biomarkers include SMN2 copy number, SMN mRNA and protein levels, neurofilament proteins (NFs), plasma protein analytes, creatine kinase (CK) and creatinine (Crn), and various electrophysiology and imaging measures. SMN2 copy number inversely correlates with disease severity and is the best predictor of clinical outcome in untreated individuals. SMN mRNA and protein are commonly measured in the blood or CSF of patients receiving SMA therapies, particularly those aimed at increasing SMN protein expression, and provide insight into current disease state. NFs have proven to be robust prognostic, disease progression, and pharmacodynamic markers for SMA infants undergoing treatment, but less so for adolescents and adults. Select plasma proteins are altered in SMA individuals and may track response to therapy. CK and Crn from blood correlate with motor function and disease severity status and are useful for predicting which individuals will respond to therapy. Electrophysiology measures comprise the most reliable means for monitoring motor function throughout disease course and are sensitive enough to detect neuromuscular changes before overt clinical manifestation, making them robust predictive and pharmacodynamic biomarkers. Finally, magnetic resonance imaging and muscle ultrasonography are non-invasive techniques for studying muscle structure and physiology and are useful diagnostic tools, but cannot reliably track disease progression. Importantly, biomarkers can provide information about the underlying mechanisms of disease as well as reveal subclinical disease progression, allowing for more appropriate timing and dosing of therapy for individuals with SMA. Recent therapeutic advancements in SMA have shown promising results, though there is still a great need to identify and understand the impact of biomarkers in modulating disease onset and progression.
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Affiliation(s)
- Megan G Pino
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Kelly A Rich
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
| | - Stephen J Kolb
- Department of Neurology, The Ohio State
University Wexner Medical Center, Columbus, OH, USA
- Department of Biological Chemistry and
Pharmacology, The Ohio State University Wexner Medical Center, Columbus, OH,
USA
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25
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Boulay C, Delmont E, Audic F, Chabrol B, Attarian S. Motor unit number index: A potential electrophysiological biomarker for pediatric spinal muscular atrophy. Muscle Nerve 2021; 64:445-453. [PMID: 34255873 DOI: 10.1002/mus.27372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 07/05/2021] [Accepted: 07/09/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS In adult spinal muscular atrophy (SMA), the motor unit number index (MUNIX) has been shown to be an useful electrophysiological biomarker. This study evaluated the feasibility and the clinical relevance of using the MUNIX technique for patients with pediatric SMA (Ped-SMA) and correlated MUNIX results with clinical scores. METHODS Fourteen patients with type II Ped-SMA (11 females; median age 11 y [interquartile range (IQR), 4.8-17 y]) and 14 controls (nine females; median age 10.75 y [IQR, 6.5-13.4 y]) were enrolled and matched by sex, age, height, weight, and body mass index. Clinical examination included manual muscle testing, dynamometry (grasp and pinch), and motor function measure (MFM). The MUNIX technique was evaluated in the abductor digiti minimi (ADM) and abductor pollicis brevis (APB) on two sides when possible. RESULTS In the patients with Ped-SMA, the MUNIX and compound muscle action potential (CMAP) amplitudes were significantly decreased and the motor size unit index (MUSIX) was significantly increased in the ADM and APB when compared to controls. The intraclass correlation coefficient was good for the intrarater variability of the CMAP amplitude, MUNIX, and MUSIX in the ADM (0.95, 0.83, and 0.89, respectively) and the APB (0.98, 0.96, and 0.94, respectively). The total CMAP amplitude correlated with the grasp and pinch scores (P < .05), and the MUNIX measurements correlated with the MFM scores. DISCUSSION The MUNIX technique, which accurately estimated lower motor neuron loss and the number of remaining functional motor units, was shown to be a useful electrophysiological biomarker for disease progression and a potential biomarker for treatment response.
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Affiliation(s)
- Christophe Boulay
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, CNRS, ISM UMR 7287, Marseille, France
| | - Emilien Delmont
- Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, UMR 7286, Medicine Faculty, Marseille, France
| | - Frédérique Audic
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France
| | - Brigitte Chabrol
- Neuropediatric Department, Children Timone University Hospital, Aix-Marseille University, Marseille, France.,Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, Inserm UMR S 910, Medical Genetics and Functional Genomics, Marseille, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS Timone University Hospital, Aix-Marseille University, Marseille, France.,Aix-Marseille University, Inserm UMR S 910, Medical Genetics and Functional Genomics, Marseille, France
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26
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Makary MM, Weerasekara A, Rodham H, Hightower BG, Tseng CEJ, Chan J, Chew S, Paganoni S, Ratai EM, Zürcher NR, Hooker JM, Atassi N, Babu S. Comparison of Two Clinical Upper Motor Neuron Burden Rating Scales in ALS Using Quantitative Brain Imaging. ACS Chem Neurosci 2021; 12:906-916. [PMID: 33576234 DOI: 10.1021/acschemneuro.0c00772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Several clinical upper motor neuron burden scales (UMNSs) variably measure brain dysfunction in amyotrophic lateral sclerosis (ALS). Here, we compare relationship of two widely used clinical UMNSs in ALS (Penn and MGH UMNSs) with (a) neuroimaging markers of brain dysfunction and (b) neurological impairment status using the gold-standard functional measure, the revised ALS Functional Rating Scale (ALSFRS-R). MGH UMNS measures hyperreflexia alone, and Penn UMNS measures hyperreflexia, spasticity, and pseudobulbar affect. Twenty-eight ALS participants underwent both Penn and MGH UMNSs, at a matching time-point as a simultaneous [11C]PBR28 positron emission tomography (PBR28-PET)/Magnetic Resonance scan and ALSFRS-R. The two UMNSs were compared for localization and strength of association with neuroimaging markers of: (a) neuroinflammation, PBR28-PET and MR Spectroscopy metabolites (myo-inositol and choline) and (b) corticospinal axonal loss, fractional anisotropy (FA), and MR Spectroscopy metabolite (N-acetylaspartate). Among clinical UMN manifestations, segmental hyperreflexia, spasticity, and pseudobulbar affect occurred in 100, 43, and 18% ALS participants, respectively. Pseudobulbar affect did not map to any specific brain regional dysfunction, while hyperreflexia and spasticity subdomains significantly correlated and colocalized neurobiological changes to corticospinal pathways on whole brain voxel-wise analyses. Both UMNS total scores showed significant and similar strength of association with (a) neuroimaging changes (PBR28-PET, FA, MR Spectroscopy metabolites) in primary motor cortices and (b) severity of functional decline (ALSFRS-R). Hyperreflexia is the most frequent clinical UMN manifestation and correlates best with UMN molecular imaging changes in ALS. Among Penn UMNS's subdomains, hyperreflexia carries the weight of association with neuroimaging markers of biological changes in ALS. A clinical UMN scale comprising hyperreflexia items alone is clinically relevant and sufficient to predict the highest yield of molecular neuroimaging abnormalities in ALS.
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Affiliation(s)
- Meena M. Makary
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
- Systems and Biomedical Engineering Department, Faculty of Engineering, Cairo University, Giza, 12613, Egypt
| | - Akila Weerasekara
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Haley Rodham
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Baileigh G. Hightower
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Chieh-En J. Tseng
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - James Chan
- Department of Biostatistics, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02115, United States
| | - Sheena Chew
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
| | - Sabrina Paganoni
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
- Department of PM&R, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts 02129, United States
| | - Eva-Maria Ratai
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Nicole R. Zürcher
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Jacob M. Hooker
- Department of Radiology, Massachusetts General Hospital, A. A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, Massachusetts 02129, United States
| | - Nazem Atassi
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
- Sanofi Genzyme, Cambridge, Massachusetts 02142, United States
| | - Suma Babu
- Sean M Healey & AMG Center for ALS, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, United States
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27
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Querin G, Lenglet T, Debs R, Stojkovic T, Behin A, Salachas F, Le Forestier N, Amador MDM, Bruneteau G, Laforêt P, Blancho S, Marchand-Pauvert V, Bede P, Hogrel JY, Pradat PF. Development of new outcome measures for adult SMA type III and IV: a multimodal longitudinal study. J Neurol 2021; 268:1792-1802. [PMID: 33388927 DOI: 10.1007/s00415-020-10332-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was the comprehensive characterisation of longitudinal clinical, electrophysiological and neuroimaging measures in type III and IV adult spinal muscular atrophy (SMA) with a view to propose objective monitoring markers for future clinical trials. METHODS Fourteen type III or IV SMA patients underwent standardised assessments including muscle strength testing, functional evaluation (SMAFRS and MFM), MUNIX (abductor pollicis brevis, APB; abductor digiti minimi, ADM; deltoid; tibialis anterior, TA; trapezius) and quantitative cervical spinal cord MRI to appraise segmental grey and white matter atrophy. Patients underwent a follow-up assessment with the same protocol 24 months later. Longitudinal comparisons were conducted using the Wilcoxon-test for matched data. Responsiveness was estimated using standardized response means (SRM) and a composite score was generated based on the three most significant variables. RESULTS Significant functional decline was observed based on SMAFRS (p = 0.019), pinch and knee flexion strength (p = 0.030 and 0.027), MUNIX and MUSIX value in the ADM (p = 0.0006 and 0.043) and in TA muscle (p = 0.025). No significant differences were observed based on cervical MRI measures. A significant reduction was detected in the composite score (p = 0.0005, SRM = -1.52), which was the most responsive variable and required a smaller number of patients than single variables in the estimation of sample size for clinical trials. CONCLUSIONS Quantitative strength testing, SMAFRS and MUNIX readily capture disease progression in adult SMA patients. Composite multimodal scores increase predictive value and may reduce sample size requirements in clinical trials.
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Affiliation(s)
- Giorgia Querin
- Centre de Référence Maladies Neuromusculaires Paris-Est, APHP, Hôpital Pitié-Salpêtrière, Service de Neuromyologie, Paris, France
- Laboratoire D'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France
- Institut de Myologie, I-Motion Adultes Plateforme, Paris, France
| | - Timothée Lenglet
- Département de Neurophysiologie, APHP, Hôpital Pitié-Salpêtrière, Paris, France
- APHP, Centre Référant SLA, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rabab Debs
- Département de Neurophysiologie, APHP, Hôpital Pitié-Salpêtrière, Paris, France
| | - Tanya Stojkovic
- Centre de Référence Maladies Neuromusculaires Paris-Est, APHP, Hôpital Pitié-Salpêtrière, Service de Neuromyologie, Paris, France
| | - Anthony Behin
- Centre de Référence Maladies Neuromusculaires Paris-Est, APHP, Hôpital Pitié-Salpêtrière, Service de Neuromyologie, Paris, France
| | | | - Nadine Le Forestier
- APHP, Centre Référant SLA, Hôpital Pitié-Salpêtrière, Paris, France
- Département de Recherche en Éthique, EA 1610: Etudes Des Sciences Et Techniques, Université Paris Sud/Paris Saclay, Paris, France
| | | | - Gaëlle Bruneteau
- APHP, Centre Référant SLA, Hôpital Pitié-Salpêtrière, Paris, France
| | - Pascal Laforêt
- Neurology Department, Nord/Est/Ile de France Neuromuscular Center, Raymond-Poincaré Hospital, Garches, France
- INSERM U1179, END-ICAP, Versailles Saint-Quentin-en-Yvelines University, Montigny-le-Bretonneux, France
| | - Sophie Blancho
- Institut Pour La Recherche Sur La Moelle Epinière Et L'Encéphale (IRME), Paris, France
| | | | - Peter Bede
- Laboratoire D'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France
- APHP, Centre Référant SLA, Hôpital Pitié-Salpêtrière, Paris, France
- Computational Neuroimaging Group, Academic Unit of Neurology, Trinity College, Dublin, Ireland
| | - Jean-Yves Hogrel
- Institute of Myology, Neuromuscular Investigation Center, Paris, France
| | - Pierre-François Pradat
- Laboratoire D'Imagerie Biomédicale, Sorbonne Université, CNRS, INSERM, Paris, France.
- APHP, Centre Référant SLA, Hôpital Pitié-Salpêtrière, Paris, France.
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute Ulster University, Altnagelvin Hospital, Derry/Londonderry, C-TRIC, UK.
- Département de Neurologie, 47 Boulevard de l'sHôpital, 75634, Paris cedex 13, France.
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28
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Neuwirth C, Weber M. MUNIX
in children with spinal muscular atrophy: An unexpected journey. Muscle Nerve 2020; 62:565-566. [DOI: 10.1002/mus.27053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/19/2020] [Accepted: 08/22/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Christoph Neuwirth
- Neuromuscular Diseases Unit/ALS Clinic Kantonsspital St Gallen St Gallen Switzerland
| | - Markus Weber
- Neuromuscular Diseases Unit/ALS Clinic Kantonsspital St Gallen St Gallen Switzerland
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29
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Lawley A, Abbas A, Seri S, Rajabally YA. Peripheral nerve electrophysiology studies in relation to fatigue in patients with chronic inflammatory demyelinating polyneuropathy. Clin Neurophysiol 2020; 131:2926-2931. [PMID: 32928696 DOI: 10.1016/j.clinph.2020.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 07/07/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To explore the relationship between fatigue, standard electrophysiological parameters and number and size of functioning motor units in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS Experienced fatigue was assessed using the linearly-weighted, modified Rasch-built fatigue severity scale (R-FSS) and the multidimensional Checklist of Individual Strength (CIS). Averaged electrophysiology values were calculated from multiple nerves. Motor Unit Number Index (MUNIX) technique was utilised to assess motor unit function. Assessments were repeated in 15 patients receiving regular intravenous immunoglobulin therapy, with changes in parameters calculated. RESULTS R-FSS and CIS scores did not correlate MUNIX or MUSIX sum scores from 3 different muscles. Inverse correlation was observed only between distal CMAP area and R-FSS but not CIS scores. However, changes in distal CMAP area and R-FSS scores on repeat assessment were not correlated. CONCLUSIONS Experienced fatigue does not appear to correlate with loss of functioning motor units in patients with CIDP. Changes in experienced fatigue on repeat assessment did not correlate with changes in any of the electrophysiological parameters, suggesting fatigue experienced in CIDP is not strongly correlated with peripheral nerve dysfunction. SIGNIFICANCE Nerve conduction studies and MUNIX values do not appear to be useful surrogate markers for fatigue in CIDP.
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Affiliation(s)
- Andrew Lawley
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK; Department of Clinical Neurophysiology, The Birmingham Women's and Children's Hospital NHS Foundation Trust, UK
| | - Ahmed Abbas
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Birmingham, UK
| | - Stefano Seri
- School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, UK; Department of Clinical Neurophysiology, The Birmingham Women's and Children's Hospital NHS Foundation Trust, UK
| | - Yusuf A Rajabally
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Birmingham, UK; Aston Medical School, Aston University, Birmingham, UK.
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30
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Delmont E, Wang F, Lefaucheur JP, Puma A, Breniere C, Beaudonnet G, Cintas P, Collin R, Fortanier E, Grapperon AM, Jomir L, Kribich H, Kouton L, Kuntzer T, Lenglet T, Magot A, Nordine T, Ochsner F, Bolloy G, Pereon Y, Salort-Campana E, Tard C, Vicino A, Verschueren A, Attarian S. Motor unit number index as an individual biomarker: Reference limits of intra-individual variability over time in healthy subjects. Clin Neurophysiol 2020; 131:2209-2215. [PMID: 32707479 DOI: 10.1016/j.clinph.2020.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/13/2020] [Accepted: 06/05/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Motor unit number index (MUNIX) is proposed to monitor neuromuscular disorders. Our objective is to determine the intra-individual variability over time of the MUNIX. METHODS In 11 different hospital centres, MUNIX was assessed twice, at least 3 months apart (range 90-360 days), in tibialis anterior (TA), abductor pollicis brevis (APB), abductor digiti minimi (ADM) and deltoid muscles in 118 healthy subjects. MUNIX sum score 2, 3 and 4 were respectively the sum of the MUNIX of the TA and ADM, of the TA, APB and ADM and of the TA, APB, ADM and deltoid muscles. RESULTS The repeatability of the MUNIX was better for sum scores than for single muscle recordings. The variability of the MUNIX was independent of sex, age, interval between measurements and was lower for experienced than non-experienced operators. The 95th percentile of the coefficient of variability of the MUNIX sum score 2, 3 and 4 were respectively 22%, 18% and 15% for experienced operators. CONCLUSIONS The MUNIX technique must be performed by experienced operators on several muscles to reduce its variability and improve its reliability. SIGNIFICANCE A variation of the MUNIX sum score ≥20% can be interpreted as a significant change of muscle innervation.
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Affiliation(s)
- Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France; Aix-Marseille University, Timone Neuroscience Institute, UMR CNRS 7289, 13005 Marseille, France.
| | - François Wang
- Department of Neurophysiology, CHU Sart Tilman B35, 4000 Liège, Belgium
| | - Jean-Pascal Lefaucheur
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France; Unité de Neurophysiologie Clinique, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - Angela Puma
- Université Côte d'Azur, Peripheral Nervous System and Muscle Department, CHU Nice, France
| | | | - Guillemette Beaudonnet
- Unité de Neurophysiologie Clinique et Epileptologie, CHU Bicêtre, Le Kremlin Bicêtre, France
| | | | - Romain Collin
- Department of Neurophysiology, CHU Sart Tilman B35, 4000 Liège, Belgium
| | - Etienne Fortanier
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
| | - Aude-Marie Grapperon
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
| | - Laurent Jomir
- Department of Neurology, Hospices Civiles de Lyon, France
| | - Hafida Kribich
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
| | - Ludivine Kouton
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
| | - Thierry Kuntzer
- Nerve Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Timothee Lenglet
- Department of Clinical Neurophysiology, APHP, Pitié-Salpêtrière Hospital, Paris, France
| | - Armelle Magot
- Laboratoire d'explorations fonctionnelles, Referral Centre for Neuromuscular Disease Atlantique-Occitanie-Caraïbes, Hôtel-Dieu, 44093 Nantes, France
| | - Tarik Nordine
- EA 4391, Excitabilité Nerveuse et Thérapeutique, Université Paris-Est-Créteil, Créteil, France; Unité de Neurophysiologie Clinique, Hôpital Henri Mondor, Assistance Publique - Hôpitaux de Paris, Créteil, France
| | - François Ochsner
- Nerve Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Gaëlle Bolloy
- Laboratoire d'explorations fonctionnelles, Referral Centre for Neuromuscular Disease Atlantique-Occitanie-Caraïbes, Hôtel-Dieu, 44093 Nantes, France
| | - Yann Pereon
- Laboratoire d'explorations fonctionnelles, Referral Centre for Neuromuscular Disease Atlantique-Occitanie-Caraïbes, Hôtel-Dieu, 44093 Nantes, France
| | | | - Céline Tard
- U1172 Lille Neuroscience et Cognition, CHU de Lille, Centre de référence des maladies neuromusculaires Nord Est Ile de France, Department of Neurology, Lille, France
| | - Alex Vicino
- Nerve Muscle Unit, Department of Clinical Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | - Annie Verschueren
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS, La Timone Hospital, Marseille, France
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van Eijk RP, Kliest T, McDermott CJ, Roes KC, Van Damme P, Chio A, Weber M, Ingre C, Corcia P, Povedano M, Reviers E, van Es MA, Al-Chalabi A, Hardiman O, van den Berg LH. TRICALS: creating a highway toward a cure. Amyotroph Lateral Scler Frontotemporal Degener 2020; 21:496-501. [DOI: 10.1080/21678421.2020.1788092] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ruben P.A. van Eijk
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
- Biostatistics & Research Support, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Tessa Kliest
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Christopher J. McDermott
- Department of Neuroscience, University of Sheffield, Sheffield Institute for Translational Neuroscience, Sheffield, UK
| | - Kit C.B. Roes
- Department of Health Evidence, Section Biostatistics, Radboud Medical Centre Nijmegen, the Netherlands
| | - Philip Van Damme
- Department of Neurosciences, Laboratory for Neurobiology, KU Leuven and Center for Brain & Disease Research, VIB, Leuven Brain Institute, Leuven, Belgium
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
| | - Adriano Chio
- Rita Levi Montalcini’ Department of Neuroscience, ALS Centre, University of Torino, Turin, Italy
- Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Markus Weber
- Neuromoscular Disease Unit/ALS Clinic, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Caroline Ingre
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Philippe Corcia
- Centre Constitutif SLA, CHRU de Tours - Fédération des centres SLA Tours-Limoges, LitORALS, Tours, France
| | - Mònica Povedano
- Functional Unit of Amyotrophic Lateral Sclerosis (UFELA), Service of Neurology, Bellvitge University Hospital, Hospitalet de Llobregat, Spain
| | - Evy Reviers
- European Organization for Professionals and Patients with ALS (EUpALS), Leuven, Belgium
| | - Michael A. van Es
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Ammar Al-Chalabi
- Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute and United Kingdom Dementia Research Institute Centre, King’s College London, London, UK
- Department of Neurology, King’s College Hospital, London, UK
| | - Orla Hardiman
- Department of Neurology, National Neuroscience Centre, Beaumont Hospital, Dublin, Ireland, and
- FutureNeuro SFI Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Leonard H. van den Berg
- Department of Neurology, UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
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32
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Verma S, Forte J, Ritchey M, Shah D. Motor unit number index in children with later-onset spinal muscular atrophy. Muscle Nerve 2020; 62:633-637. [PMID: 32369629 DOI: 10.1002/mus.26909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Motor unit number index (MUNIX) is a validated electrophysiological biomarker in amyotrophic lateral sclerosis. MUNIX studies in spinal muscular atrophy (SMA) are limited. METHODS Later-onset SMA children (n = 13; three SMN2 copy number) were evaluated for Hammersmith Motor Function Scale Expanded (HMFSE) and MUNIX of right abductor pollicis brevis (APB) and abductor digiti minimi (ADM) muscles. Age-matched healthy controls (n = 8) were enrolled to obtain normative APB and ADM MUNIX values. RESULTS Mean APB and ADM MUNIX values in SMA subjects were significantly reduced (P < .001) compared with controls. HMFSE scores strongly correlated with ADM MUNIX (r 0.63). CONCLUSIONS APB and ADM muscle MUNIX studies are feasible in SMA type 2 children. ADM MUNIX correlated with disease severity on motor function testing. MUNIX studies in later-onset SMA could be a potential biomarker of motor neuron loss.
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Affiliation(s)
- Sumit Verma
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Jasmine Forte
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.,Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Mary Ritchey
- Department of Physical Therapy, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Durga Shah
- Department of Physical Therapy, Children's Healthcare of Atlanta, Atlanta, Georgia
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Bashford J, Mills K, Shaw C. The evolving role of surface electromyography in amyotrophic lateral sclerosis: A systematic review. Clin Neurophysiol 2020; 131:942-950. [PMID: 32044239 PMCID: PMC7083223 DOI: 10.1016/j.clinph.2019.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/23/2019] [Accepted: 12/14/2019] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Amyotrophic lateral sclerosis (ALS) is an adult-onset neurodegenerative disease that leads to inexorable motor decline and a median survival of three years from symptom onset. Surface EMG represents a major technological advance that has been harnessed in the development of novel neurophysiological biomarkers. We have systematically reviewed the current application of surface EMG techniques in ALS. METHODS We searched PubMed to identify 42 studies focusing on surface EMG and its associated analytical methods in the diagnosis, prognosis and monitoring of ALS patients. RESULTS A wide variety of analytical techniques were identified, involving motor unit decomposition from high-density grids, motor unit number estimation and measurements of neuronal hyperexcitability or neuromuscular architecture. Some studies have proposed specific diagnostic and prognostic criteria however clinical calibration in large ALS cohorts is currently lacking. The most validated method to monitor disease is the motor unit number index (MUNIX), which has been implemented as an outcome measure in two ALS clinical trials. CONCLUSION Surface EMG offers significant practical and analytical flexibility compared to invasive techniques. To capitalise on this fully, emphasis must be placed upon the multi-disciplinary collaboration of clinicians, bioengineers, mathematicians and biostatisticians. SIGNIFICANCE Surface EMG techniques can enrich effective biomarker development in ALS.
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Affiliation(s)
- J. Bashford
- UK Dementia Research Institute, Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
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Gao F, Cao Y, Zhang C, Zhang Y. A Preliminary Study of Effects of Channel Number and Location on the Repeatability of Motor Unit Number Index (MUNIX). Front Neurol 2020; 11:191. [PMID: 32256444 PMCID: PMC7090144 DOI: 10.3389/fneur.2020.00191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 02/28/2020] [Indexed: 01/01/2023] Open
Affiliation(s)
- Farong Gao
- School of Automation, Artificial Intelligence Institute, Hangzhou Dianzi University, Hangzhou, China
| | - Yueying Cao
- School of Automation, Artificial Intelligence Institute, Hangzhou Dianzi University, Hangzhou, China
| | - Chuan Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
| | - Yingchun Zhang
- Department of Biomedical Engineering, University of Houston, Houston, TX, United States
- *Correspondence: Yingchun Zhang
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Higashihara M, Menon P, van den Bos M, Pavey N, Vucic S. Reproducibility of motor unit number index and MScanFit motor unit number estimation across intrinsic hand muscles. Muscle Nerve 2020; 62:192-200. [PMID: 32077117 DOI: 10.1002/mus.26839] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/09/2020] [Accepted: 02/15/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We sought to evaluate the reproducibility of the motor unit number index (MUNIX) and MScanFit motor unit number estimation (MScan) when recording was performed over intrinsic hand muscles. METHODS The compound muscle action potential (CMAP) amplitude, MUNIX, and MScan were measured from the abductor pollicis brevis (APB), first dorsal interosseous (FDI), and abductor digit minimi (ADM) muscles from 15 healthy volunteers on three different occasions. RESULTS The reproducibility of CMAP amplitudes was excellent, with intraclass correlation coefficients (ICC) of 0.86 (APB), 0.90 (FDI), and 0.96 (ADM). Motor unit number index (ICCAPB 0.73, ICCFDI 0.85, ICCADM 0.85) and MScan (ICCAPB 0.86, ICCFDI 0.83, ICCADM 0.81) were highly reproducible across the three muscles. There were no significant correlations between MUNIX and MScan coefficients of variation (CV) and CMAP amplitude CVs. DISCUSSION Reproducibility of MUNIX and MScan was not significantly different across the intrinsic hand muscles and was independent of CMAP amplitude variability.
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Affiliation(s)
- Mana Higashihara
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Parvathi Menon
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Mehdi van den Bos
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Nathan Pavey
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
| | - Steve Vucic
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
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[Treatment evaluation in patients with 5q-associated spinal muscular atrophy : Real-world experience]. DER NERVENARZT 2019; 90:343-351. [PMID: 30617569 DOI: 10.1007/s00115-018-0653-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Spinal muscular atrophy (SMA) is a progressive autosomal recessive neurodegenerative disease with an incidence of 1:10,000 live births. With a deeper understanding of the molecular basis of SMA in the past two decades, a major focus of therapeutic development has been on increasing the proportion of functionally capable SMN protein by increasing the inclusion of exon 7 in SMN2 transcripts, enhancing SMN2 gene expression, stabilizing the SMN protein or replacing the SMN1 gene. Since June 2017, the antisense oligonucleotide nusinersen/Spinraza® (Biogen GmbH, Ismaning, Germany) has been approved for 5qSMA treatment. Nusinersen modifies premessenger RNA splicing of exon 7, leading to stable SMN protein expression and for the first time an effective disease-modifying treatment is available. In several controlled trials nusinersen showed a favorable benefit-risk profile along with clinically relevant improvements in motor function. The efficacy was most pronounced in presymptomatic patients, which underlines the necessity for a newborn screening program and is the key to start efficient treatment prior to motor neuron death. The repeated intrathecal administration of nusinersen is associated with practical challenges, in particular for patients with severe scoliosis or after spinal straightening surgery. As the vast majority of SMA patients were outside previous study populations regarding age and disease duration, experts complained about a lack of data on efficacy and safety beyond childhood. To fill these gaps a systematic data collection has been initiated by the SMArtCARE initiative, aiming at collecting comprehensive data in the clinical routine, regardless of the patients' individual treatment regimen.
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Motor unit number index and compound muscle action potential amplitude. Clin Neurophysiol 2019; 130:1734-1740. [DOI: 10.1016/j.clinph.2019.05.031] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/05/2019] [Accepted: 05/13/2019] [Indexed: 12/11/2022]
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Gomes de Sousa MW, Escorcio-Bezerra ML, Pinto WBVR, Souza PVS, de Oliveira Braga NI, Oliveira ASB, Manzano GM. Motor unit number index (MUNIX) in myopathic disorders: Clinical correlations and potential pitfalls. Neurophysiol Clin 2019; 49:329-334. [PMID: 31331650 DOI: 10.1016/j.neucli.2019.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/02/2019] [Accepted: 07/06/2019] [Indexed: 12/13/2022] Open
Abstract
Our aim was to study motor unit number index (MUNIX) in myopathic disorders. We studied 11 patients with myopathy, and healthy controls. We obtained MUNIX, compound muscle action potential (CMAP), motor unit size index (MUSIX) and alpha (α, power exponent from MUNIX equation) measurements from three different muscles. MUNIX and CMAP were significantly lower in one muscle. This MUNIX decrease may not be related to motor neuron loss, but rather to muscle fiber atrophy. MUSIX and α did not change and may be useful in determining whether the MUNIX decrease is indeed due to motor unit loss.
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Verber NS, Shepheard SR, Sassani M, McDonough HE, Moore SA, Alix JJP, Wilkinson ID, Jenkins TM, Shaw PJ. Biomarkers in Motor Neuron Disease: A State of the Art Review. Front Neurol 2019; 10:291. [PMID: 31001186 PMCID: PMC6456669 DOI: 10.3389/fneur.2019.00291] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 03/06/2019] [Indexed: 12/17/2022] Open
Abstract
Motor neuron disease can be viewed as an umbrella term describing a heterogeneous group of conditions, all of which are relentlessly progressive and ultimately fatal. The average life expectancy is 2 years, but with a broad range of months to decades. Biomarker research deepens disease understanding through exploration of pathophysiological mechanisms which, in turn, highlights targets for novel therapies. It also allows differentiation of the disease population into sub-groups, which serves two general purposes: (a) provides clinicians with information to better guide their patients in terms of disease progression, and (b) guides clinical trial design so that an intervention may be shown to be effective if population variation is controlled for. Biomarkers also have the potential to provide monitoring during clinical trials to ensure target engagement. This review highlights biomarkers that have emerged from the fields of systemic measurements including biochemistry (blood, cerebrospinal fluid, and urine analysis); imaging and electrophysiology, and gives examples of how a combinatorial approach may yield the best results. We emphasize the importance of systematic sample collection and analysis, and the need to correlate biomarker findings with detailed phenotype and genotype data.
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Affiliation(s)
- Nick S Verber
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Stephanie R Shepheard
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Matilde Sassani
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Harry E McDonough
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Sophie A Moore
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - James J P Alix
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Iain D Wilkinson
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Tom M Jenkins
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
| | - Pamela J Shaw
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience (SITraN), University of Sheffield, Sheffield, United Kingdom
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Chipika RH, Finegan E, Li Hi Shing S, Hardiman O, Bede P. Tracking a Fast-Moving Disease: Longitudinal Markers, Monitoring, and Clinical Trial Endpoints in ALS. Front Neurol 2019; 10:229. [PMID: 30941088 PMCID: PMC6433752 DOI: 10.3389/fneur.2019.00229] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 02/22/2019] [Indexed: 12/13/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) encompasses a heterogeneous group of phenotypes with different progression rates, varying degree of extra-motor involvement and divergent progression patterns. The natural history of ALS is increasingly evaluated by large, multi-time point longitudinal studies, many of which now incorporate presymptomatic and post-mortem assessments. These studies not only have the potential to characterize patterns of anatomical propagation, molecular mechanisms of disease spread, but also to identify pragmatic monitoring markers. Sensitive markers of progressive neurodegenerative change are indispensable for clinical trials and individualized patient care. Biofluid markers, neuroimaging indices, electrophysiological markers, rating scales, questionnaires, and other disease-specific instruments have divergent sensitivity profiles. The discussion of candidate monitoring markers in ALS has a dual academic and clinical relevance, and is particularly timely given the increasing number of pharmacological trials. The objective of this paper is to provide a comprehensive and critical review of longitudinal studies in ALS, focusing on the sensitivity profile of established and emerging monitoring markers.
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Affiliation(s)
| | - Eoin Finegan
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Stacey Li Hi Shing
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Orla Hardiman
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Alix JJP, Neuwirth C, Gelder L, Burkhardt C, Castro J, de Carvalho M, Gawel M, Goedee S, Grosskreutz J, Lenglet T, Moglia C, Omer T, Schrooten M, Nandedkar S, Stalberg E, Barkhaus PE, Furtula J, van Dijk JP, Baldinger R, Costa J, Otto M, Sandberg A, Weber M. Assessment of the reliability of the motor unit size index (MUSIX) in single subject "round-robin" and multi-centre settings. Clin Neurophysiol 2019; 130:666-674. [PMID: 30870802 DOI: 10.1016/j.clinph.2019.01.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 11/16/2018] [Accepted: 01/03/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The motor unit size index (MUSIX) is incorporated into the motor unit number index (MUNIX). Our objective was to assess the intra-/inter-rater reliability of MUSIX in healthy volunteers across single subject "round robin" and multi-centre settings. METHODS Data were obtained from (i) a round-robin assessment in which 12 raters (6 with prior experience and 6 without) assessed six muscles (abductor pollicis brevis, abductor digiti minimi, biceps brachii, tibialis anterior, extensor digitorum brevis and abductor hallucis) and (ii) a multi-centre study with 6 centres studying the same muscles in 66 healthy volunteers. Intra/inter-rater data were provided by 5 centres, 1 centre provided only intra-rater data. Intra/inter-rater variability was assessed using the coefficient of variation (COV), Bland-Altman plots, bias and 95% limits of agreement. RESULTS In the round-robin assessment intra-rater COVs for MUSIX ranged from 7.8% to 28.4%. Inter-rater variability was between 7.8% and 16.2%. Prior experience did not impact on MUSIX values. In the multi-centre study MUSIX was more consistent than the MUNIX. Abductor hallucis was the least reliable muscle. CONCLUSIONS The MUSIX is a reliable neurophysiological biomarker of reinnervation. SIGNIFICANCE MUSIX could provide insights into the pathophysiology of a range of neuromuscular disorders, providing a quantitative biomarker of reinnervation.
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Affiliation(s)
- James J P Alix
- Sheffield Institute for Translational Neuroscience, University of Sheffield, 385A Glossop Road, Sheffield S10 2HQ, UK.
| | - Christoph Neuwirth
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | - Lucy Gelder
- Statistical Services Unit, University of Sheffield, UK
| | - Christian Burkhardt
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | - José Castro
- Department of Neurosciences, Hospital de Santa Maria, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Portugal
| | - Mamede de Carvalho
- Department of Neurosciences, Hospital de Santa Maria, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Portugal
| | - Malgorzata Gawel
- Department of Neurology, Medical University of Warsaw, Warsaw, Poland
| | - Stephan Goedee
- Brain Centre Rudolf Magnus, Department of Neurology and Neurosurgery, UMC Utrecht, Utrecht, The Netherlands
| | - Julian Grosskreutz
- Hans-Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Timothée Lenglet
- Département de Neurophysiologie, Groupe hospitalier Pitié-Salpêtrière, APHP, Paris, France
| | - Cristina Moglia
- ALS Centre of Torino, Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Taha Omer
- Trinity College Biomedical Science Institute (TBSI) and Beaumont Hospital, Dublin, Ireland
| | - Maarten Schrooten
- Department of Neurology, University Hospital Leuven, Leuven, Belgium
| | - Sanjeev Nandedkar
- Natus Medical, Inc., 15 Dartantra Drive, Hopewell Junction, NY 12533, USA
| | - Erik Stalberg
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden
| | - Paul E Barkhaus
- Milwaukee Veterans Administration Medical Center and Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jasna Furtula
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Reto Baldinger
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
| | - Joao Costa
- Department of Neurosciences, Hospital de Santa Maria, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Portugal
| | - Marit Otto
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Arne Sandberg
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden
| | - Markus Weber
- Neuromuscular Diseases Unit/ALS Clinic, Kantonsspital, St. Gallen, Switzerland
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Günther R, Neuwirth C, Koch JC, Lingor P, Braun N, Untucht R, Petzold D, Weber M, Hermann A. Motor Unit Number Index (MUNIX) of hand muscles is a disease biomarker for adult spinal muscular atrophy. Clin Neurophysiol 2018; 130:315-319. [PMID: 30528741 DOI: 10.1016/j.clinph.2018.11.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 09/25/2018] [Accepted: 11/11/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE There is still insufficient knowledge about natural history in adult spinal muscular atrophy, thus valid markers for treatment and disease monitoring are urgently needed. METHODS We studied hand muscle innervation pattern of 38 adult genetically confirmed 5q spinal muscular atrophy (SMA) patients by the motor unit number index (MUNIX) method. Data were compared to healthy controls and amyotrophic lateral sclerosis (ALS) patients and systematically correlated to typical disease-relevant scores and other clinical as well as demographic characteristics. RESULTS Denervation of hand muscles in adult SMA was not evenly distributed. By calculation of the MUNIX ratios, we identified a specific hand muscle wasting pattern for SMA which is different to the split hand in ALS. Furthermore, MUNIX parameters strongly correlated with established disease course parameters independent of disease stages. CONCLUSION We found a pathophysiological remarkable denervation pattern of hand muscles, a 'reversed split hand'. MUNIX of single hand muscles correlated well with disease severity and thus represents an easily available biomarker for adult SMA. SIGNIFICANCE Our data show the power of the MUNIX method as a biomarker for upcoming questions in adult SMA.
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Affiliation(s)
- René Günther
- Department of Neurology, Technische Universität Dresden, Dresden, Germany; German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany.
| | - Christoph Neuwirth
- Neuromuscular Disease Unit/ALS Clinic, Kantonspital St. Gallen, St. Gallen, Switzerland.
| | - Jan Christoph Koch
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
| | - Paul Lingor
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany; Cluster of Excellence Nanoscale Microscopy and Molecular Physiology of the Brain (CNMPB), Germany.
| | - Nathalie Braun
- Neuromuscular Disease Unit/ALS Clinic, Kantonspital St. Gallen, St. Gallen, Switzerland.
| | - Robert Untucht
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.
| | - Daniel Petzold
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.
| | - Markus Weber
- Neuromuscular Disease Unit/ALS Clinic, Kantonspital St. Gallen, St. Gallen, Switzerland.
| | - Andreas Hermann
- Department of Neurology, Technische Universität Dresden, Dresden, Germany; German Center for Neurodegenerative Diseases (DZNE), Dresden, Germany.
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Escorcio-Bezerra ML, Abrahao A, Nunes KF, de Castro Sparapani FV, de Oliveira Braga NI, Robinson LR, Zinman L, Manzano GM. Optimal E2 (reference) electrode placement in fibular motor nerve conduction studies recording from the tibialis anterior muscle. Muscle Nerve 2018; 59:249-253. [PMID: 30370536 DOI: 10.1002/mus.26366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 12/13/2022]
Abstract
INTRODUCTION In this study we aimed to determine the contribution of the E2 (reference electrode) to the compound muscle action potential (CMAP) amplitude during fibular motor recording to the tibialis anterior (TA) when E2 is placed over routine referential vs. alternative sites. METHODS The CMAP was obtained from 10 healthy subjects, using the active electrode (E1) over sites routinely used as E2 for the TA, whereas the E2 was over the contralateral knee. The same procedure was performed with the E1 over alternative E2 sites. RESULTS Significant electrical signal was captured over routine E2 placement sites. Among the tested alternative E2 sites, the ipsilateral patella (especially its medial aspect) was the most electrically silent. DISCUSSION Using alternative E2 sites with near isoelectric recordings can optimize near-field potential measurement in the fibular motor recording to the TA and represents a more accurate way of measuring nerve and muscle function. Muscle Nerve 59:249-253, 2019.
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Affiliation(s)
- Marcio Luiz Escorcio-Bezerra
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, 04039-002, Brazil
| | - Agessandro Abrahao
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, 04039-002, Brazil.,Sunnybrook Health Sciences Centre, Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karlo Faria Nunes
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, 04039-002, Brazil
| | | | | | - Lawrence R Robinson
- Sunnybrook Health Sciences Centre, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lorne Zinman
- Sunnybrook Health Sciences Centre, Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gilberto Mastrocola Manzano
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Rua Pedro de Toledo, 650, 04039-002, Brazil
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Garcia-Santibanez R, Burford M, Bucelli RC. Hereditary Motor Neuropathies and Amyotrophic Lateral Sclerosis: a Molecular and Clinical Update. Curr Neurol Neurosci Rep 2018; 18:93. [DOI: 10.1007/s11910-018-0901-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Fatehi F, Grapperon AM, Fathi D, Delmont E, Attarian S. The utility of motor unit number index: A systematic review. Neurophysiol Clin 2018; 48:251-259. [PMID: 30287192 DOI: 10.1016/j.neucli.2018.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 09/04/2018] [Accepted: 09/11/2018] [Indexed: 12/11/2022] Open
Abstract
The need for a valid biomarker for assessing disease progression and for use in clinical trials on amyotrophic lateral sclerosis (ALS) has stimulated the study of methods that could measure the number of motor units. Motor unit number index (MUNIX) is a newly developed neurophysiological technique that was demonstrated to have a good correlation with the number of motor units in a given muscle, even though it does not necessarily accurately express the actual number of viable motor neurons. Several studies demonstrated the technique is reproducible and capable of following motor neuron loss in patients with ALS and peripheral polyneuropathies. The main goal of this review was to conduct an extensive review of the literature using MUNIX. We conducted a systematic search in English medical literature published in two databases (PubMed and SCOPUS). In this review, we aimed to answer the following queries: Comparison of MUNIX with other MUNE techniques; the reproducibility of MUNIX; the utility of MUNIX in ALS and preclinical muscles, peripheral neuropathies, and other neurological disorders.
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Affiliation(s)
- Farzad Fatehi
- Reference Center for Neuromuscular Diseases and ALS, Timone University Hospital, 13385 Marseille, France; Department of Neurology, Iranian Center of Neurological Research, Neuroscience Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Aude-Marie Grapperon
- Reference Center for Neuromuscular Diseases and ALS, Timone University Hospital, 13385 Marseille, France
| | - Davood Fathi
- Department of Neurology, Iranian Center of Neurological Research, Neuroscience Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran; Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Emilien Delmont
- Reference Center for Neuromuscular Diseases and ALS, Timone University Hospital, 13385 Marseille, France
| | - Shahram Attarian
- Reference Center for Neuromuscular Diseases and ALS, Timone University Hospital, 13385 Marseille, France; Inserm, GMGF, Aix-Marseille University, Marseille, 13385 France.
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46
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Barkhaus PE. Motor Unit Number Index (MUNIX) and the Chowkidar. Clin Neurophysiol 2018; 129:1714-1715. [PMID: 29880329 DOI: 10.1016/j.clinph.2018.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 05/09/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Paul E Barkhaus
- Medical College of Wisconsin, Department of Neurology, 8701 Watertown Plank Road, Milwaukee, Wisconsin 53226, USA.
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