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Sanfilippo MJ, Layshock ME, Keniston L. Exploring the association between outcome measures to guide clinical management in patients with amyotrophic lateral sclerosis. J Phys Ther Sci 2022; 34:532-539. [PMID: 35937622 PMCID: PMC9345750 DOI: 10.1589/jpts.34.532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/02/2022] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The usefulness and limitations of outcome measures changes throughout
functional decline of patients with Amyotrophic Lateral Sclerosis (ALS). This study aims
to describe associations between outcome measures in patients with ALS over time.
[Participants and Methods] Participant data was collected at a multidisciplinary ALS
clinic during regular clinic visits, including gait velocity, Timed Up and Go, the ALS
Functional Rating Scale-Revised, and it’s Gross Motor Subscale. [Results] All gait
velocity measures were <1.2 m/sec; average Timed Up and Go was >13.5 sec. There was
strong internal consistency between ALS Functional Rating Scale-Revised and its functional
mobility components and a strong, significant correlation between the Timed Up and Go and
the Gross Motor Subscale. [Conclusion] Patients with ALS are not community ambulators and
demonstrate risk for falls. We found concurrent validity between objective and
self-reported measures. The strong association between the Gross Motor Subscale and the
Timed Up and Go may allow PTs to utilize the self-reported Gross Motor Subscale to predict
fall risk. Clinically, when the Timed Up and Go and gait velocity are no longer
appropriate due to disease progression, the Gross Motor Subscale can provide insight into
functional decline.
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Affiliation(s)
- Michelle J Sanfilippo
- Department of Physical Therapy, University of Maryland Eastern Shore: 1 College Backbone Road, Princess Anne, MD 21853, USA
| | - Mary E Layshock
- Department of Physical Therapy, University of Maryland Eastern Shore: 1 College Backbone Road, Princess Anne, MD 21853, USA
| | - Leslie Keniston
- Department of Physical Therapy, University of Maryland Eastern Shore: 1 College Backbone Road, Princess Anne, MD 21853, USA
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Heskamp L, Miller AR, Birkbeck MG, Hall J, Schofield I, Blamire AM, Whittaker RG. In vivo 3D imaging of human motor units in upper and lower limb muscles. Clin Neurophysiol 2022; 141:91-100. [PMID: 35853787 DOI: 10.1016/j.clinph.2022.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess in-vivo cross-sectional and 3D morphology of human motor units in hand, forearm and lower leg muscles using magnetic resonance imaging (MRI). METHODS Diffusion weighted MRI was used with in-scanner electrical stimulation in healthy controls to image motor units at a single slice in lower leg, forearm and hand muscles (n = 6) and multiple slices in the lower leg for 3D assessment (n = 7). RESULTS Motor unit cross-sectional area (CSA) and maximum Feret diameter (FDmax) did not differ between the lower leg (CSA: 22.4 ± 8.4 mm2; FDmax: 8.7 ± 2.4 mm), forearm (CSA: 23.6 ± 14.1 mm2; FDmax: 9.0 ± 3.3 mm) and hand (CSA: 26.8 ± 12.8 mm2 and FDmax: 9.6 ± 2.7 mm) (ANOVA; p = 0.487 and p = 0.587, respectively). Lower leg motor units were 8.0 ± 3.8 cm long with largest CSA in the motor unit's middle section. 3D motor unit imaging revealed a complex structure with several units splitting and re-forming along their length. CONCLUSIONS Motor unit MRI (MUMRI) can be applied to upper limb muscles, and can reveal the 3D structure of human motor units in-vivo. SIGNIFICANCE MUMRI provides the first in-vivo 2D images of upper limb motor units and 3D images of lower leg motor units. 3D imaging suggest a more complex human motor unit structure than previously thought.
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Kang X, Quan D. Electrodiagnostic Assessment of Motor Neuron Disease. Neurol Clin 2021; 39:1071-1081. [PMID: 34602215 DOI: 10.1016/j.ncl.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Motor neuron diseases involve degeneration of motor neurons in the brain (upper motor neurons), brain stem, and spinal cord (lower motor neurons). Symptoms vary depending on the degree of upper and lower neuron involvement, but progressive painless weakness is the predominant complaint. Motor neuron disease includes numerous specific disorders, including amyotrophic lateral sclerosis, spinal muscular atrophy, spinal bulbar muscular atrophy, and other inherited and acquired conditions. Abnormalities on nerve conduction studies, repetitive nerve stimulation, needle electromyography, and other electrodiagnostic techniques help to distinguish these disorders from each other, and from other disorders with progressive weakness.
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Affiliation(s)
- Xuan Kang
- Department of Neurology, University of Colorado Denver, Academic Office 1, 12631 East 17th Avenue, Mailstop B185, Aurora, CO 80045, USA
| | - Dianna Quan
- Department of Neurology, University of Colorado Denver, Academic Office 1, 12631 East 17th Avenue, Mailstop B185, Aurora, CO 80045, USA.
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Abstract
The concept, definition, and diagnosis of amyotrophic lateral sclerosis (ALS) currently present some problems. This article systematically reviews the literature on the history, current concepts, definition, and diagnosis of ALS, and discloses the present problems based on the retrieved literature and the authors’ clinical experience. The current concepts and definitions of ALS have not yet been unified or standardized in clinical practice, and are sometimes vague or inaccurate, which can cause difficulties for neurologists in the clinical treatment of ALS. The concept and definition of ALS need to be further ascertained, and the current diagnostic criteria for ALS require further development. The identification of effective and objective biomarkers may be a feasible method for the early and accurate diagnosis of ALS. Therefore, future research should focus on the identification of reliable biomarkers—especially neuroimaging biomarkers—through autopsy. Standardizing the concept and definition of ALS and formulating clear diagnostic criteria will largely avoid many uncertainties in the future clinical research and treatment of ALS, which will greatly benefit patients.
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Affiliation(s)
- Ren-Shi Xu
- Department of Neurology, Jiangxi provincial People's Hospital, Affiliated People's Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Min Yuan
- Department of Neurology, Jiangxi provincial People's Hospital, Affiliated People's Hospital of Nanchang University, Nanchang, Jiangxi Province, China
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Cengiz B, Kuruoğlu R. A new parameter to discriminate amyotrophic lateral sclerosis patients from healthy participants by motor cortical excitability changes. Muscle Nerve 2020; 61:354-362. [PMID: 31875983 DOI: 10.1002/mus.26786] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/08/2019] [Accepted: 12/22/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION We sought a combination of abnormalities to define a more sensitive measure of cortical excitability in amyotrophic lateral sclerosis (ALS). METHODS The automatic threshold tracking method was employed to assess the resting motor threshold, intracortical facilitation (ICF), short-interval intracortical inhibition (SICI), and short-interval intracortical faciilitation (SICF) in patients and controls. RESULTS SICF at interstimulus intervals (ISI) between 1 and 1.8 ms and 2 and 3 ms as well as average SICI and SICI at ISIs of 1 and 2.5 ms were significantly reduced in ALS. The SICI curve was altered, displaying a solitary peak. Discriminant analysis revealed that the combination of SICI 2.5 ms and the mean SICF between 1 and 1.8 ms ISIs was the most sensitive parameter to distinguish patients with ALS from healthy participants. DISCUSSION Along with the reduced SICI and its altered shape, connectivity between motor cortical circuits is changed in ALS. Combination with SICF increases the diagnostic utility of SICI in ALS.
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Affiliation(s)
- Bülent Cengiz
- Department of Neurology, Clinical Neurophysiology Division, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Reha Kuruoğlu
- Department of Neurology, Clinical Neurophysiology Division, Gazi University Faculty of Medicine, Ankara, Turkey
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Cook C, Petrucelli L. Genetic Convergence Brings Clarity to the Enigmatic Red Line in ALS. Neuron 2019; 101:1057-1069. [PMID: 30897357 DOI: 10.1016/j.neuron.2019.02.032] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/07/2019] [Accepted: 02/19/2019] [Indexed: 12/11/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is an aggressive neurodegenerative disorder that orchestrates an attack on the motor nervous system that is unrelenting. Recent discoveries into the pathogenic consequences of repeat expansions in C9ORF72, which are the most common genetic cause of ALS, combined with the identification of new genetic mutations are providing novel insight into the underlying mechanism(s) that cause ALS. In particular, the myriad of functions linked to ALS-associated genes have collectively implicated four main pathways in disease pathogenesis, including RNA metabolism and translational biology; protein quality control; cytoskeletal integrity and trafficking; and mitochondrial function and transport. Through the identification of common disease mechanisms on which multiple ALS genes converge, key targets for potential therapeutic intervention are highlighted.
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Affiliation(s)
- Casey Cook
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA; Neurobiology of Disease Graduate Program, Mayo Clinic Graduate School of Biomedical Sciences, Jacksonville, FL, USA
| | - Leonard Petrucelli
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL, USA; Neurobiology of Disease Graduate Program, Mayo Clinic Graduate School of Biomedical Sciences, Jacksonville, FL, USA.
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Menon P, Yiannikas C, Kiernan MC, Vucic S. Regional motor cortex dysfunction in amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2019; 6:1373-1382. [PMID: 31402622 PMCID: PMC6689694 DOI: 10.1002/acn3.50819] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE The pathophysiological processes underlying amyotrophic lateral sclerosis (ALS) need to be better understood, although cortical dysfunction has been implicated. Previous transcranial magnetic stimulation (TMS) studies have assessed cortical dysfunction from the hand. The aim of the present study was to determine whether cortical dysfunction was evident across representations of three body regions, and to relate these changes to clinical features of ALS. METHODS In this cross-sectional study, threshold tracking TMS was undertaken in 60 sporadic ALS patients, with motor evoked potential (MEP) responses recorded over the hand (abductor pollicis brevis), lower limb (tibialis anterior), and bulbar (trapezius) regions. The cross-sectional findings were compared to 28 age- and gender-matched controls. RESULTS Cortical dysfunction was evident across the representation of the three body regions, although the degree and nature of the dysfunction varied. Cortical hyperexcitability, as heralded by reduced short interval intracortical inhibition (SICI), was evident in all cortical regions (hand, P < 0.01; leg, P < 0.05; bulbar, P < 0.05) in ALS patients when compared with healthy control subjects. Importantly, features of cortical hyperexcitability seemed more prominent in clinically affected body regions and correlated with functional disability and muscle weakness. Cortical inexcitability was more prominent in the leg (P < 0.001) and bulbar regions (P < 0.01) when compared with controls. INTERPRETATION The nature of cortical dysfunction varied across the body regions in ALS, with cortical hyperexcitability being more prominent in the upper limbs while cortical inexcitability was more evident in the lower limbs and bulbar regions. The findings suggest a heterogeneity of cortical pathophysiological processes in ALS.
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Affiliation(s)
- Parvathi Menon
- Westmead HospitalSydneyNew South WalesAustralia
- University of SydneySydneyNew South WalesAustralia
| | - Con Yiannikas
- University of SydneySydneyNew South WalesAustralia
- Concord HospitalSydneyNew South WalesAustralia
| | - Matthew C. Kiernan
- University of SydneySydneyNew South WalesAustralia
- Brain and Mind InstituteSydneyNew South WalesAustralia
| | - Steve Vucic
- Westmead HospitalSydneyNew South WalesAustralia
- University of SydneySydneyNew South WalesAustralia
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Donatelli G, Caldarazzo Ienco E, Costagli M, Migaleddu G, Cecchi P, Siciliano G, Cosottini M. MRI cortical feature of bulbar impairment in patients with amyotrophic lateral sclerosis. Neuroimage Clin 2019; 24:101934. [PMID: 31377555 PMCID: PMC6698695 DOI: 10.1016/j.nicl.2019.101934] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 02/07/2023]
Abstract
The decline of voluntary bulbar functions such as speech and swallowing are among the clinical manifestations of amyotrophic lateral sclerosis (ALS) influencing a worst prognosis. Differential diagnosis between the contribution of upper motor neuron (UMN) and lower motor neuron degeneration to the bulbar impairment is often hard. Thinning and T2* hypointensity of the primary motor cortex have been recently suggested as possible MRI markers of UMN impairment in ALS patients, but little research has purposely targeted the orofacial region of the primary motor cortex (fM1). With the aim of finding an MRI marker of UMN impairment responsible for bulbar dysfunction, we investigated the T2* signal intensity of fM1 and the relationship with bulbar impairment in ALS patients. Fifty-five ALS patients were examined with 3 T MRI. Their fM1 was evaluated both qualitatively in terms of T2* signal intensity and quantitatively by measuring its magnetic susceptibility with Quantitative Susceptibility Mapping (QSM). Bulbar functions were assessed clinically, by neurological examination and using the items 1–3 of the ALSFRS-R, and with neurophysiological tests. The marked hypointensity of fM1 was detected in 25% of ALS patients, including all patients with bulbar onset, and was 74% sensitive, 100% specific and 91% accurate in diagnosing functional bulbar impairment. Such hypointensity involved the middle and ventral part of fM1 and was usually visible in both hemispheres. The magnetic susceptibility was significantly higher in patients with marked fM1 hypointensity than in the other patients (p ≤ .001). The relationship with clinical and neurophysiological data suggests that such feature could be a marker of UMN degeneration for voluntary bulbar functions. T2* hypointensity was assessed in the orofacial region of M1 (fM1) of ALS patients. All ALS patients with marked T2* hypointensity of fM1 had bulbar impairment (BI). The marked T2* hypointensity of fM1 was 91% accurate in diagnosing BI. fM1 hypointensity can be a marker of upper motor neuron degeneration causing BI.
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Affiliation(s)
- Graziella Donatelli
- Imago7 Research Foundation, Pisa, Italy; Neuroradiology Unit, Azienda Ospadaliero-Universitaria Pisana, Pisa, Italy
| | - Elena Caldarazzo Ienco
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mauro Costagli
- Imago7 Research Foundation, Pisa, Italy; Laboratory of Medical Physics and Magnetic Resonance, IRCCS Stella Maris, Pisa, Italy.
| | - Gianmichele Migaleddu
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Paolo Cecchi
- Neuroradiology Unit, Azienda Ospadaliero-Universitaria Pisana, Pisa, Italy
| | - Gabriele Siciliano
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospadaliero-Universitaria Pisana, Pisa, Italy; Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Liu J, Zhang X, Ding X, Song M, Sui K. Analysis of clinical and electrophysiological characteristics of 150 patients with amyotrophic lateral sclerosis in China. Neurol Sci 2019; 40:363-9. [DOI: 10.1007/s10072-018-3633-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 11/01/2018] [Indexed: 12/13/2022]
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10
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Abstract
Electrodiagnostic testing provides insight into subclinical aspects of disease in amyotrophic lateral sclerosis and helps to diagnose and exclude other diagnoses. It may also help to manage or track disease progression. Mapping the extent of subclinical disease may guide the clinician to supportive interventions. There is considerable interest in establishing electrodiagnostic biomarkers to monitor disease progression. This article details the usefulness of electrodiagnostic testing across the disease spectrum. A review of clinical presentations and differential diagnoses, diagnostic evaluation, and emerging applications of electrodiagnostic studies to guide management and assess response to treatment interventions are presented with considerations for clinical practice.
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11
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Donatelli G, Ceravolo R, Frosini D, Tosetti M, Bonuccelli U, Cosottini M. Present and Future of Ultra-High Field MRI in Neurodegenerative Disorders. Curr Neurol Neurosci Rep 2018; 18. [DOI: 10.1007/s11910-018-0841-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sangari S, Giron A, Marrelec G, Pradat PF, Marchand-Pauvert V. Abnormal cortical brain integration of somatosensory afferents in ALS. Clin Neurophysiol 2017; 129:874-884. [PMID: 29317192 DOI: 10.1016/j.clinph.2017.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 11/25/2017] [Accepted: 12/11/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Infraclinical sensory alterations have been reported at early stages of amyotrophic lateral sclerosis (ALS). While previous studies mainly focused on early somatosensory evoked potentials (SEPs), late SEPs, which reflect on cortical pathways involved in cognitive-motor functions, are relatively underinvestigated. Early and late SEPs were compared to assess their alterations in ALS. METHODS Median and ulnar nerves were electrically stimulated at the wrist, at 9 times the perceptual threshold, in 21 ALS patients without clinical evidence of sensory deficits, and 21 age- and gender-matched controls. SEPs were recorded at the Erb point using surface electrodes and using a needle inserted in the scalp, in front of the primary somatosensory area (with reference electrode on the ear lobe). RESULTS Compared to controls, ALS patients showed comparable peripheral (N9) and early cortical component (N20, P25, N30) reductions, while the late cortical components (N60, P100) were more depressed than the early ones. CONCLUSIONS The peripheral sensory alteration likely contributed to late SEP depression to a lesser extent than that of early SEPs. SIGNIFICANCE Late SEPs may provide new insights on abnormal cortical excitability affecting brain areas involved in cognitive-motor functions.
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Affiliation(s)
- Sina Sangari
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, Inserm, Laboratoire d'Imagerie Biomédicale, F-75013 Paris, France
| | - Alain Giron
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, Inserm, Laboratoire d'Imagerie Biomédicale, F-75013 Paris, France
| | - Guillaume Marrelec
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, Inserm, Laboratoire d'Imagerie Biomédicale, F-75013 Paris, France
| | - Pierre-François Pradat
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, Inserm, Laboratoire d'Imagerie Biomédicale, F-75013 Paris, France; Département de Neurologie, AP-HP, Hôpital Pitié-Salpêtrière, F-75013 Paris, France
| | - Véronique Marchand-Pauvert
- Sorbonne Universités, UPMC Univ Paris 06, CNRS, Inserm, Laboratoire d'Imagerie Biomédicale, F-75013 Paris, France.
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Donatelli G, Retico A, Caldarazzo Ienco E, Cecchi P, Costagli M, Frosini D, Biagi L, Tosetti M, Siciliano G, Cosottini M. Semiautomated Evaluation of the Primary Motor Cortex in Patients with Amyotrophic Lateral Sclerosis at 3T. AJNR Am J Neuroradiol 2017; 39:63-69. [PMID: 29122765 DOI: 10.3174/ajnr.a5423] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/13/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Amyotrophic lateral sclerosis is a neurodegenerative disease involving the upper and lower motor neurons. In amyotrophic lateral sclerosis, pathologic changes in the primary motor cortex include Betz cell depletion and the presence of reactive iron-loaded microglia, detectable on 7T MR images as atrophy and T2*-hypointensity. Our purposes were the following: 1) to investigate the signal hypointensity-to-thickness ratio of the primary motor cortex as a radiologic marker of upper motor neuron involvement in amyotrophic lateral sclerosis with a semiautomated method at 3T, 2) to compare 3T and 7T results, and 3) to evaluate whether semiautomated measurement outperforms visual image assessment. MATERIALS AND METHODS We investigated 27 patients and 13 healthy subjects at 3T, and 19 patients and 18 healthy subjects at 7T, performing a high-resolution 3D multiecho T2*-weighted sequence targeting the primary motor cortex. The signal hypointensity-to-thickness ratio of the primary motor cortex was calculated with a semiautomated method depicting signal intensity profiles of the cortex. Images were also visually classified as "pathologic" or "nonpathologic" based on the primary motor cortex signal intensity and thickness. RESULTS The signal hypointensity-to-thickness ratio of the primary motor cortex was greater in patients than in controls (P < .001), and it correlated with upper motor neuron impairment in patients (ρ = 0.57, P < .001). The diagnostic accuracy of the signal hypointensity-to-thickness ratio was high at 3T (area under the curve = 0.89) and even higher at 7T (area under the curve = 0.94). The sensitivity of the semiautomated method (0.81) outperformed the sensitivity of the visual assessment (0.56-0.63) at 3T. CONCLUSIONS The signal hypointensity-to-thickness ratio of the primary motor cortex calculated with a semiautomated method is suggested as a radiologic marker of upper motor neuron burden in patients with amyotrophic lateral sclerosis. This semiautomated method may be useful for improving the subjective radiologic evaluation of upper motor neuron pathology in patients suspected of having amyotrophic lateral sclerosis.
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Affiliation(s)
- G Donatelli
- From the Department of Translational Research and New Technologies in Medicine and Surgery (G.D., P.C., M. Cosottini)
| | - A Retico
- National Institute for Nuclear Physics (A.R.), Pisa Division, Pisa, Italy
| | - E Caldarazzo Ienco
- Neurology Unit, Department of Clinical and Experimental Medicine (E.C.I., D.F., G.S.), University of Pisa, Pisa, Italy
| | - P Cecchi
- From the Department of Translational Research and New Technologies in Medicine and Surgery (G.D., P.C., M. Cosottini)
| | - M Costagli
- Imago7 Research Foundation (M. Costagli, L.B., M.T.), Pisa, Italy.,Laboratory of Medical Physics and Biotechnologies for Magnetic Resonance (M. Costagli, L.B., M.T.), Istituto di Ricovero e Cura a Carattere Scientifico Stella Maris, Pisa, Italy
| | - D Frosini
- Neurology Unit, Department of Clinical and Experimental Medicine (E.C.I., D.F., G.S.), University of Pisa, Pisa, Italy
| | - L Biagi
- Imago7 Research Foundation (M. Costagli, L.B., M.T.), Pisa, Italy.,Laboratory of Medical Physics and Biotechnologies for Magnetic Resonance (M. Costagli, L.B., M.T.), Istituto di Ricovero e Cura a Carattere Scientifico Stella Maris, Pisa, Italy
| | - M Tosetti
- Imago7 Research Foundation (M. Costagli, L.B., M.T.), Pisa, Italy.,Laboratory of Medical Physics and Biotechnologies for Magnetic Resonance (M. Costagli, L.B., M.T.), Istituto di Ricovero e Cura a Carattere Scientifico Stella Maris, Pisa, Italy
| | - G Siciliano
- Neurology Unit, Department of Clinical and Experimental Medicine (E.C.I., D.F., G.S.), University of Pisa, Pisa, Italy
| | - M Cosottini
- From the Department of Translational Research and New Technologies in Medicine and Surgery (G.D., P.C., M. Cosottini)
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Abstract
BACKGROUND Motor neuron disease (MND), which is also known as amyotrophic lateral sclerosis (ALS), causes a wide range of symptoms but the evidence base for the effectiveness of the symptomatic treatment therapies is limited. OBJECTIVES To summarise the evidence from Cochrane Systematic Reviews of all symptomatic treatments for MND. METHODS We searched the Cochrane Database of Systematic Reviews (CDSR) on 15 November 2016 for systematic reviews of symptomatic treatments for MND. We assessed the methodological quality of the included reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the GRADE approach. We followed standard Cochrane study (review) selection and data extraction procedures. We reported findings narratively and in tables. MAIN RESULTS We included nine Cochrane Systematic Reviews of interventions to treat symptoms in people with MND. Three were empty reviews with no included randomised controlled trials (RCTs); however, all three reported on non-RCT evidence and the remaining six included mostly one or two studies. We deemed all of the included reviews of high methodological quality. Drug therapy for painThere is no RCT evidence in a Cochrane Systematic Review exploring the efficacy of drug therapy for pain in MND. Treatment for crampsThere is evidence (13 RCTs, N = 4012) that for the treatment of cramps in MND, compared to placebo:- memantine and tetrahydrocannabinol (THC) are probably ineffective (moderate-quality evidence);- vitamin E may have little or no effect (low-quality evidence); and- the effects of L-threonine, gabapentin, xaliproden, riluzole, and baclofen are uncertain as the evidence is either very low quality or the trial specified the outcome but did not report numerical data.The review reported adverse effects of riluzole, but it is not clear whether other interventions had adverse effects. Treatment for spasticityIt is uncertain whether an endurance-based exercise programme improved spasticity or quality of life, measured at three months after the programme, as the quality of evidence is very low (1 RCT, comparison "usual activities", N = 25). The review did not evaluate other approaches, such as use of baclofen as no RCTs were available. Mechanical ventilation for supporting respiratory functionNon-invasive ventilation (NIV) probably improves median survival and quality of life in people with respiratory insufficiency and normal to moderately impaired bulbar function compared to standard care, and improves quality of life but not survival for people with poor bulbar function (1 RCT, N = 41, moderate-quality evidence; a second RCT did not provide data). The review did not evaluate other approaches such as tracheostomy-assisted ('invasive') ventilation, or assess timing of NIV initiation. Treatment for sialorrhoeaA single session of botulinum toxin type B injections to parotid and submandibular glands probably improves sialorrhoea and quality of life at up to 4 weeks compared to placebo injections, but not at 8 or 12 weeks after the injections (moderate-quality evidence from 1 placebo-controlled RCT, N = 20). The review authors found no trials of other approaches. Enteral tube feeding for supporting nutritionThere is no RCT evidence in a Cochrane Systematic Review to support benefit or harms of enteral tube feeding in supporting nutrition in MND. Repetitive transcranial magnetic stimulationIt is uncertain whether repetitive transcranial magnetic stimulation (rTMS) improves disability or limitation in activity in MND in comparison with sham rTMS (3 RCTs, very low quality evidence, N = 50). Therapeutic exerciseThere is evidence that exercise may improve disability in MND at three months after the exercise programme, but not quality of life, in comparison with "usual activities" or "usual care" including stretching (2 RCTs, low-quality evidence, N = 43). Multidisciplinary careThere is no RCT evidence in a Cochrane Systematic Review to demonstrate any benefit or harm for multidisciplinary care in MND.None of the reviews, other than the review of treatment for cramps, reported that adverse events occurred. However, the trials were too small for reliable adverse event reporting. AUTHORS' CONCLUSIONS This overview has highlighted the lack of robust evidence in Cochrane Systematic Reviews on interventions to manage symptoms resulting from MND. It is important to recognise that clinical trials may fail to demonstrate efficacy of an intervention for reasons other than a true lack of efficacy, for example because of insufficient statistical power, the wrong choice of dose, insensitive outcome measures or inappropriate participant eligibility. The trials were mostly too small to reliably assess adverse effects of the treatments. The nature of MND makes it difficult to research clinically accepted or recommended practice, regardless of the level of evidence supporting the practice. It would not be ethical, for example, to design a placebo-controlled trial for treatment of pain in MND or to withhold multidisciplinary care where such care is available. It is therefore highly unlikely that there will ever be classically designed placebo-controlled RCTs in these areas.We need more research with appropriate study designs, robust methodology, and of sufficient duration to address the changing needs-of people with MND and their caregivers-associated with MND disease progression and mortality. There is a significant gap in studies assessing the effectiveness of interventions for symptoms relating to MND, such as pseudobulbar emotional lability and cognitive and behavioural difficulties. Future studies should use appropriate outcome measures that are reliable, have internal and external validity, and are sensitive to change in what is being measured (such as quality of life).
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Affiliation(s)
- Louisa Ng
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
| | - Fary Khan
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
- Monash UniversityDisability Inclusive Unit, Nossal Institute of Global Health & School of Public Health and Preventative MedicineThe Alfred Centre99 Commercial RoadMelbourneVictoriaAustralia3004
- University of MelbourneDepartment of MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
- Royal Melbourne HospitalAustralian Rehabilitation Research CentreMelbourneVictoriaAustralia
| | - Carolyn A Young
- The Walton Centre NHS Foundation TrustLower LaneFazakerleyLiverpoolUKL9 7LJ
| | - Mary Galea
- Royal Melbourne Hospital, Royal Park CampusDepartment of Rehabilitation MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
- University of MelbourneDepartment of MedicinePoplar RoadParkvilleMelbourneVictoriaAustralia3052
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Kaur SJ, McKeown SR, Rashid S. Mutant SOD1 mediated pathogenesis of Amyotrophic Lateral Sclerosis. Gene. 2016;577:109-118. [PMID: 26657039 DOI: 10.1016/j.gene.2015.11.049] [Citation(s) in RCA: 199] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/27/2015] [Accepted: 11/30/2015] [Indexed: 12/13/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neural disorder that causes death of the motor neurons in the brain and spinal cord; this affects the voluntary muscles and gradually leads to paralysis of the whole body. Most ALS cases are sporadic, though about 5-10% are familial. ALS is caused by multiple factors including mutation in any one of a number of specific genes, one of the most frequently affected is superoxide dismutase (SOD) 1. Alterations in SOD 1 have been linked with several variants of familial ALS. SOD 1 is a powerful antioxidant enzyme that protects cells from the damaging effects of superoxide radicals. The enzyme binds both copper and zinc ions that are directly involved in the deactivation of toxic superoxide radicals. Mutated SOD1 gene can acquire both gain and loss of function mutations. The most commonly identified mutations in SOD1 that affect protein activity are D90A, A4V and G93A. Deleterious mutations have been shown to modify SOD1 activity, which leads to the accumulation of highly toxic hydroxyl radicals. Accumulation of these free radicals causes degradation of both nuclear and mitochondrial DNA and protein misfolding, features which can be used as pathological indicators associated with ALS. Numerous clinical trials have been carried out over last few years with limited success. In some patients advanced techniques like gene and stem cell therapy have been trialed. However no definitive treatment option can provide a cure and currently ALS is managed by drugs and other supportive therapies. Consequently there is a need to identify new approaches for treatment of this ultimately fatal disease.
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Abstract
Amyotrophic lateral sclerosis (ALS) is characterized by progressive degeneration of upper and lower motor neurons, with variable involvement of extramotor brain regions. Currently, there are no established objective markers of upper motor neuron and extramotor involvement in ALS. Here, we review the potential diagnostic value of advanced neuroimaging techniques that are increasingly being used to study the brain in ALS. First, we discuss the role of different imaging modalities in our increasing understanding of ALS pathogenesis, and their potential to contribute to objective upper motor neuron biomarkers for the disease. Second, we discuss the challenges to be overcome and the required phases of diagnostic test development to translate imaging technology to clinical care. We also present examples of multidimensional imaging approaches to achieve high levels of diagnostic accuracy. Last, we address the role of neuroimaging in clinical therapeutic trials. Advanced neuroimaging techniques will continue to develop and offer significant opportunities to facilitate the development of new effective treatments for ALS.
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Affiliation(s)
- Esther Verstraete
- />Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Bradley R. Foerster
- />Department of Radiology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109 USA
- />Ann Arbor VA Healthcare System, Ann Arbor, MI USA
- />Russell H. Morgan Department of Radiology, Johns Hopkins University, Baltimore, MD USA
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Mancuso R, Osta R, Navarro X. Presymptomatic electrophysiological tests predict clinical onset and survival in SOD1(G93A) ALS mice. Muscle Nerve 2014; 50:943-9. [PMID: 24619579 DOI: 10.1002/mus.24237] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2014] [Indexed: 12/11/2022]
Abstract
INTRODUCTION We assessed the predictive value of electrophysiological tests as a marker of clinical disease onset and survival in superoxide-dismutase 1 (SOD1)(G93A) mice. METHODS We evaluated the accuracy of electrophysiological tests in differentiating transgenic versus wild-type mice. We made a correlation analysis of electrophysiological parameters and the onset of symptoms, survival, and number of spinal motoneurons. RESULTS Presymptomatic electrophysiological tests show great accuracy in differentiating transgenic versus wild-type mice, with the most sensitive parameter being the tibialis anterior compound muscle action potential (CMAP) amplitude. The CMAP amplitude at age 10 weeks correlated significantly with clinical disease onset and survival. Electrophysiological tests increased their survival prediction accuracy when evaluated at later stages of the disease and also predicted the amount of lumbar spinal motoneuron preservation. CONCLUSIONS Electrophysiological tests predict clinical disease onset, survival, and spinal motoneuron preservation in SOD1(G93A) mice. This is a methodological improvement for preclinical studies.
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Affiliation(s)
- Renzo Mancuso
- Group of Neuroplasticity and Regeneration, Institute of Neurosciences and Department of Cell Biology, Physiology and Immunology, Universitat Autònoma de Barcelona, and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
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Pizzimenti A, Aragona M, Onesti E, Inghilleri M. Depression, pain and quality of life in patients with amyotrophic lateral sclerosis: a cross-sectional study. Funct Neurol 2014; 28:115-9. [PMID: 24125561 DOI: 10.11138/fneur/2013.28.2.115] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The complications related to amyotrophic lateral sclerosis (ALS) include pain. A higher risk of depression and a negative effect on quality of life (QoL) might be expected in ALS patients with pain. The aims of this study were to evaluate the prevalence of pain in ALS patients, to compare measures of depression and QoL in patients with and without pain, and to study the influence of depression scores and pain on the QoL of ALS patients with pain. Forty ALS patients were enrolled, and 36 were included in the analysis. Seventy-two percent of patients reported pain. Pain intensity was significantly related to a worsening of QoL (p<.05). This effect was no longer significant after considering depression scores as a covariate. Depression scores significantly decreased QoL (p<.02) and this effect remained significant after considering pain intensity as a covariate (p<.05). Our study suggests that pain is frequent in ALS patients and that depressive symptoms are significantly related to poorer QoL. Clinicians should pay more attention to both pain and depressive symptoms in ALS patients considering their effect on QoL.
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Foerster BR, Carlos RC, Dwamena BA, Callaghan BC, Petrou M, Edden RAE, Mohamed MA, Welsh RC, Barker PB, Feldman EL, Pomper MG. Multimodal MRI as a diagnostic biomarker for amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2014; 1:107-14. [PMID: 25356389 PMCID: PMC4212480 DOI: 10.1002/acn3.30] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Revised: 12/16/2013] [Accepted: 12/17/2013] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Reliable biomarkers for amyotrophic lateral sclerosis (ALS) are needed, given the clinical heterogeneity of the disease. Here, we provide proof-of-concept for using multimodal magnetic resonance imaging (MRI) as a diagnostic biomarker for ALS. Specifically, we evaluated the added diagnostic utility of proton magnetic resonance spectroscopy (MRS) to diffusion tensor imaging (DTI). METHODS Twenty-nine patients with ALS and 30 age- and gender-matched healthy controls underwent brain MRI which used proton MRS including spectral editing techniques to measure γ-aminobutyric acid (GABA) and DTI to measure fractional anisotropy of the corticospinal tract. Data were analyzed using logistic regression, t-tests, and generalized linear models with leave-one-out analysis to generate and compare the resulting receiver operating characteristic (ROC) curves. RESULTS The diagnostic accuracy is significantly improved when the MRS data were combined with the DTI data as compared to the DTI data only (area under the ROC curves (AUC) = 0.93 vs. AUC = 0.81; P = 0.05). The combined MRS and DTI data resulted in sensitivity of 0.93, specificity of 0.85, positive likelihood ratio of 6.20, and negative likelihood ratio of 0.08 whereas the DTI data only resulted in sensitivity of 0.86, specificity of 0.70, positive likelihood ratio of 2.87, and negative likelihood ratio of 0.20. INTERPRETATION Combining multiple advanced neuroimaging modalities significantly improves disease discrimination between ALS patients and healthy controls. These results provide an important step toward advancing a multimodal MRI approach along the diagnostic test development pathway for ALS.
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Affiliation(s)
- Bradley R Foerster
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland ; Department of Radiology, University of Michigan Ann Arbor, Michigan ; Ann Arbor VA Healthcare System Ann Arbor, Michigan
| | - Ruth C Carlos
- Department of Radiology, University of Michigan Ann Arbor, Michigan
| | - Ben A Dwamena
- Department of Radiology, University of Michigan Ann Arbor, Michigan ; Ann Arbor VA Healthcare System Ann Arbor, Michigan
| | | | - Myria Petrou
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland ; Department of Radiology, University of Michigan Ann Arbor, Michigan
| | - Richard A E Edden
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland ; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute Baltimore, Maryland
| | - Mona A Mohamed
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland ; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute Baltimore, Maryland
| | - Robert C Welsh
- Department of Radiology, University of Michigan Ann Arbor, Michigan ; Department of Psychiatry, University of Michigan Ann Arbor, Michigan
| | - Peter B Barker
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland ; F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute Baltimore, Maryland
| | - Eva L Feldman
- Department of Neurology, University of Michigan Ann Arbor, Michigan
| | - Martin G Pomper
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine Baltimore, Maryland
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Ahdab R, Créange A, Saint-Val C, Farhat WH, Lefaucheur JP. Rapidly progressive amyotrophic lateral sclerosis initially masquerading as a demyelinating neuropathy. Neurophysiol Clin 2013; 43:181-7. [PMID: 23856174 DOI: 10.1016/j.neucli.2013.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2013] [Revised: 04/30/2013] [Accepted: 05/01/2013] [Indexed: 11/17/2022] Open
Abstract
Rare cases of demyelinating neuropathy have been described in association with amyotrophic lateral sclerosis (ALS). We report two patients with typical ALS whose initial electroneuromyographic (ENMG) presentation could suggest the existence of a process of motor nerve fiber demyelination. However, subsequent ENMG examinations and the fatal course of the disease in a few months rather supported severe ongoing axonal degeneration at the origin of motor nerve conduction abnormalities. Repeated examinations could be required to distinguish between ENMG features of concomitant demyelinating neuropathy and rapidly progressive motor neuron loss in ALS.
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Affiliation(s)
- R Ahdab
- EA 4391, faculté de médecine de Créteil, université Paris Est Créteil, Créteil, France
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Affiliation(s)
- Maria Piotrkiewicz
- Department of Engineering of Nervous and Muscular System, Nałęcz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences Warsaw, Poland
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Deflorio C, Palma E, Conti L, Roseti C, Manteca A, Giacomelli E, Catalano M, Limatola C, Inghilleri M, Grassi F. Riluzole blocks human muscle acetylcholine receptors. J Physiol 2012; 590:2519-28. [PMID: 22431338 DOI: 10.1113/jphysiol.2012.230201] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Riluzole, the only drug available against amyotrophic lateral sclerosis (ALS), has recently been shown to block muscle ACh receptors (AChRs), raising concerns about possible negative side-effects on neuromuscular transmission in treated patients. In this work we studied riluzole's impact on the function of muscle AChRs in vitro and on neuromuscular transmission in ALS patients, using electrophysiological techniques. Human recombinant AChRs composed of α(1)β(1)δ subunits plus the γ or ε subunit (γ- or ε-AChR) were expressed in HEK cells or Xenopus oocytes. In both preparations, riluzole at 0.5 μm, a clinically relevant concentration, reversibly reduced the amplitude and accelerated the decay of ACh-evoked current if applied before coapplication with ACh. The action on γ-AChRs was more potent and faster than on ε-AChRs. In HEK outside-out patches, riluzole-induced block of macroscopic ACh-evoked current gradually developed during the initial milliseconds of ACh presence. Single channel recordings in HEK cells and in human myotubes from ALS patients showed that riluzole prolongs channel closed time, but has no effect on channel conductance and open duration. Finally, compound muscle action potentials (CMAPs) evoked by nerve stimulation in ALS patients remained unaltered after a 1 week suspension of riluzole treatment. These data indicate that riluzole, while apparently safe with regard to synaptic transmission, may affect the function of AChRs expressed in denervated muscle fibres of ALS patients, with biological consequences that remain to be investigated.
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Affiliation(s)
- Cristina Deflorio
- Department of Physiology and Pharmacology, Sapienza University, Rome, Italy
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Fulceri F, Bartalucci A, Paparelli S, Pasquali L, Biagioni F, Ferrucci M, Ruffoli R, Fornai F. Motor neuron pathology and behavioral alterations at late stages in a SMA mouse model. Brain Res 2012; 1442:66-75. [PMID: 22306031 DOI: 10.1016/j.brainres.2011.12.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 12/27/2011] [Accepted: 12/28/2011] [Indexed: 12/12/2022]
Abstract
Spinal muscular atrophy (SMA) is a neurogenetic autosomal recessive disorder characterized by degeneration of lower motor neurons. The validation of appropriate animal models is key in fostering SMA research. Recent studies set up an animal model showing long survival and slow disease progression. This model is knocked out for mouse SMN (Smn(-/-)) gene and carries a human mutation of the SMN1 gene (SMN1A2G), along with human SMN2 gene. In the present study we used this knock out double transgenic mouse model (SMN2(+/+); Smn(-/-); SMN1A2G(+/-)) to characterize the spinal cord pathology along with motor deficit at prolonged survival times. In particular, motor neuron loss was established stereologically (44.77%) after motor deficit reached a steady state. At this stage, spared motor neurons showed significant cell body enlargement. Moreover, similar to what was described in patients affected by SMA we found neuronal heterotopy (almost 4% of total motor neurons) in the anterior white matter. The delayed disease progression was likely to maintain fair motor activity despite a dramatic loss of large motor neurons. This provides a wonderful tool to probe novel drugs finely tuning the survival of motor neurons. In fact, small therapeutic effects protracted over considerable time intervals (even more than a year) are expected to be magnified.
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Affiliation(s)
- Federica Fulceri
- Department of Human Morphology and Applied Biology, University of Pisa, via Roma, 55, 56126, Pisa, Italy.
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Abstract
F-waves result from the discharge of the motoneurons following their antidromic activation. The F-wave appears, as an indirect (the F-wave latency decreases when the stimulation site moves away from the muscular detection) and late response (occurring after the M response). In practice, the most useful parameter is the F-wave minimal latency, provided that at least seven distinct F-waves are evoked. When the analysis is relative either to the controlateral side, or to a former examination, this parameter is one of most sensitive in electroneuromyography. F-wave evocation implies conduction along the entire peripheral nervous system, and particularly its proximal part, which is not investigated by nervous trunks conduction velocity studies. Thus, F wave study is the most useful in plexopathies and polyradiculonevritis. In the early phase of Guillain-Barré syndrome, their absence may be the unique sign indicative of proximal conduction blocks.
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Affiliation(s)
- F C Wang
- Service de médecine physique et de l'appareil locomoteur, CHU Sart Tilman, B35, 4000 Liège, Belgique.
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Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in progressive loss of bulbar and limb function. Patients typically die from respiratory failure within 3 years of symptom onset. The incidence of ALS in Europe is 2-3 cases per 100,000 individuals in the general population, and the overall lifetime risk of developing the disease is 1:400. ALS is familial in 5% of cases, and shows a Mendelian pattern of inheritance. ALS is recognized to overlap with frontotemporal dementia. Diagnosis is made on clinical grounds, using internationally recognized consensus criteria, after exclusion of conditions that can mimic ALS. The Revised ALS Functional Rating Scale is currently the most widely used assessment tool; scores are used to predict survival, and have been employed extensively in clinical trials. Riluzole remains the only effective drug, and extends the average survival of patients by 3-6 months. Optimal treatment is based on symptom management and preservation of quality of life, provided in a multidisciplinary setting. The discovery of further effective disease-modifying therapies remains a critical need for patients with this devastating condition.
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Affiliation(s)
- Orla Hardiman
- Department of Neurology, School of Medicine, Room 5.41, 5th Floor, Biomedical Science Building, Trinity College Dublin, Dublin 2, Ireland.
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Chieia MA, Oliveira ASB, Silva HCA, Gabbai AA. Amyotrophic lateral sclerosis: considerations on diagnostic criteria. Arq Neuropsiquiatr 2011; 68:837-42. [PMID: 21243238 DOI: 10.1590/s0004-282x2010000600002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Accepted: 05/18/2010] [Indexed: 11/21/2022]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder, compromising the motor neuron, characterized by progressive muscle weakness, with reserved prognosis. The diagnosis is based on inclusion and exclusion clinical criteria, since there is no specific confirmation test. The objective of this research is to critically examine the main diagnosis instrument - El Escorial revisited, from the World Federation of Neurology (1998). Of the 540 patients with initial ALS diagnosis, either probable or definite, seen at UNIFESP-EPM, 190 underwent thorough investigation, following regular clinical and therapeutic treatment for over two years. Thirty patients (15.78%) had their diagnosis completely changed. The false-positive diagnoses were related to: early age, clinical presentation of symmetry, weakness greater than atrophy, symptomatic exacerbation. In addition, three patients with myasthenia gravis developed framework for ALS, suggesting the post-synaptic disability as a sign of early disease.
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Affiliation(s)
- Marco A Chieia
- Department of Neurology and Neurosurgery, Federal University of São Paulo, SP, Brazil.
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Khedr E, Ahmed M, Hamdy A, Shawky O. Cortical excitability of amyotrophic lateral sclerosis: Transcranial magnetic stimulation study. Neurophysiol Clin 2011; 41:73-9. [DOI: 10.1016/j.neucli.2011.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 01/26/2011] [Accepted: 03/21/2011] [Indexed: 12/13/2022] Open
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Abstract
Amyotrophic lateral sclerosis (ALS) is an idiopathic, fatal neurodegenerative disease of the human motor system. In this Seminar, we summarise current concepts about the origin of the disease, what predisposes patients to develop the disorder, and discuss why all cases of ALS are not the same. In the 150 years since Charcot originally described ALS, painfully slow progress has been made towards answering these questions. We focus on what is known about ALS and where research is heading-from the small steps of extending longevity, improving therapies, undertaking clinical trials, and compiling population registries to the overarching goals of establishing the measures that guard against onset and finding the triggers for this neurodegenerative disorder.
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Affiliation(s)
- Matthew C Kiernan
- Neuroscience Research Australia and Prince of Wales Clinical School, University of New South Wales, Sydney, Australia.
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Krarup C. Lower motor neuron involvement examined by quantitative electromyography in amyotrophic lateral sclerosis. Clin Neurophysiol 2011; 122:414-22. [DOI: 10.1016/j.clinph.2010.06.027] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 06/02/2010] [Accepted: 06/04/2010] [Indexed: 10/19/2022]
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Wootz H, Enjin A, Wallén-Mackenzie A, Lindholm D, Kullander K. Reduced VGLUT2 expression increases motor neuron viability in Sod1(G93A) mice. Neurobiol Dis 2009; 37:58-66. [PMID: 19770042 DOI: 10.1016/j.nbd.2009.09.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2009] [Revised: 09/11/2009] [Accepted: 09/13/2009] [Indexed: 02/07/2023] Open
Abstract
Glutamate-induced excitotoxicity has been suggested to influence pathogenesis in amyotrophic lateral sclerosis (ALS). Vesicular glutamate transporters (VGLUTs) are responsible for transport of glutamate into synaptic vesicles. Nerve terminals that envelop motor neurons in the spinal cord contain VGLUT2 and are likely responsible for most glutamate release on motor neurons. The role of VGLUT2 in ALS and its potential role to influence motor neuron survival have not previously been studied. Here, in a mouse model of ALS, we show that genetic reduction of VGLUT2 protein levels rescues motor neurons in the lumbar spinal cord and in the brainstem as well as neuromuscular junctions in tibialis anterior. Although the number of remaining motor neurons increased, neither disease onset nor life span was affected. We also show that the motor neuron subpopulation-specific markers calcitonin/calcitonin-related polypeptide alpha (Calca) and estrogen related receptor beta (ERRbeta) respond in a similar way to reduced VGLUT2 as the whole motor neuron population suggesting that the rescued motor neurons are not of a particular motor unit type. Taken together, this suggests that reduced levels of VGLUT2 decrease motor neuron degeneration but do not prevent loss of motor neuron function in the SOD1(G93A) mouse model for ALS.
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Affiliation(s)
- Hanna Wootz
- Department of Neuroscience, Uppsala University, 75123 Uppsala, Sweden.
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de Carvalho M, Chio A, Dengler R, Hecht M, Weber M, Swash M. Neurophysiological measures in amyotrophic lateral sclerosis: Markers of progression in clinical trials. ACTA ACUST UNITED AC 2009; 6:17-28. [PMID: 16036422 DOI: 10.1080/14660820410020600] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In this review we evaluate clinical neurophysiological methods, originally described for use in diagnosis that can be applied to measurement of change during the progress of amyotrophic lateral sclerosis (ALS). Such measurements are potentially important in clinical trials, and also in clinical practice. We have assessed methods for lower and upper motor neuron function, including conventional EMG, nerve conduction and F-wave studies, the derived Neurophysiological Index, motor unit counting methods (MUNE), and transcranial magnetic motor cortex stimulation. We have also addressed the validity of measurements of electromechanical coupling. Methods for measuring muscle strength are beyond the scope of this review. We conclude that MUNE, M-wave amplitude and the Neurophysiological Index are sufficiently reliable, sensitive, and relevant to the clinical problem of ALS, to be used in clinical trials in the disease. Transcranial magnetic stimulation is of limited value, but a combination of the measurements made as part of this technique may also be useful. We conclude that clinical neurophysiological techniques should now be used in measuring change in clinical trials in ALS.
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Affiliation(s)
- Mamede de Carvalho
- Department of Neurology at Hospital de Santa Maria, Institute for Molecular Medecine, University of Lisbon, Portugal.
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Leigh PN, Swash M, Iwasaki Y, Ludolph A, Meininger V, Miller RG, Mitsumoto H, Shaw P, Tashiro K, Van Den Berg L. Amyotrophic lateral sclerosis: a consensus viewpoint on designing and implementing a clinical trial. ACTA ACUST UNITED AC 2009; 5:84-98. [PMID: 15204010 DOI: 10.1080/14660820410020187] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In November 2002, an advisory board meeting was convened by Novartis Pharma to provide recommendations and rationale for clinical trials designed to evaluate new treatments, such as TCH346, for amyotrophic lateral sclerosis (ALS). In terms of selecting appropriate outcome measures, the panel recommended the use of the ALS Functional Rating Scale (ALSFRS-R) to measure primary endpoints. A review of other key issues in this area including regional variations in the epidemiology, diagnosis and management of ALS, defining patient populations and doses of trial medication, and accommodating the likelihood of co-medication with pre-existing treatment in trial design, are discussed.
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Affiliation(s)
- P Nigel Leigh
- Department of Neurology, Institute of Psychiatry, London, UK.
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Sartucci F, Maritato P, Moscato G, Orlandi G, Calabrese R, Domenici GL, Murri L. MOTOR UNIT NUMBER ESTIMATION (MUNE) AS A QUANTITATIVE MEASURE OF DISEASE PROGRESSION AND MOTOR UNIT REORGANIZATION IN AMYOTROPHIC LATERAL SCLEROSIS. Int J Neurosci 2009; 117:1229-36. [PMID: 17654089 DOI: 10.1080/00207450600936304] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Motor Unit Number Estimation (MUNE), a technique allowing to estimate the number of functioning Motor Units (MU) in single muscles, was used to score the disease's severity and progression rate in a group of 58 patients with Amyotrophic Lateral Sclerosis (ALS). All patients underwent MUNE in the abductor digiti minimi (ADM) muscle during the diagnostic work-up (T0), after three (T1) and six (T2) months. A significant loss [p < .001] of MU and a decrease [p < .001] of the maximal M wave area at T0 was found, whereas mean step area was increased [p < .001]. During the follow-up (T1 and T2), MU loss continued, maximal M wave decreased, and mean step area increased significantly. The results confirm that MUNE is a suitable tool to quantify the pathological changes in MU in patients with ALS.
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Affiliation(s)
- F Sartucci
- Department of Neuroscience, Clinical Neurophysiology, Pisa University Medical School, Pisa, Italy.
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Abstract
Amyotrophic lateral sclerosis (ALS) or motor neuron disease (MND) shares with other neurodegenetrative disorders of the aging nervous system a polygenic, multifactorial aetiology. Less than 10% are familial and these too probably are associated with several interactive genes. The onset of ALS predates development of clinical symptoms by an unknown interval which may extend several years. The cause of neurodegeneration remains unknown but a common end-point is protein misfolding which in turn causes cell function failure. The complex nature of ALS has hindered therapeutic advances. In recent years longer survival is attributable largely to institution of non-invasive ventilation with BiPAP and timely implementation of percutaneous endoscopic gastrostomy (PEG) feeding. Symptomatic treatment has advanced improving quality of life. Several encouraging avenues of therapy for ALS are beginning to be emerge raising hope for real benefit. They include protective autoimmunity, vaccines against misfolded protein epitopes and other deleterious species, new drug delivery systems employing nanotechnology and the potential of stem cell therapy.
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Affiliation(s)
- Andrew Eisen
- Neurology, University of British Columbia, 2862 Highbury Street, Vancouver, British Columbia, V6R 3T6, Canada.
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Abstract
The terms amyotrophic lateral sclerosis (ALS) or motor neuron disease (MND) refer to a condition characterized by motor system degeneration with relative preservation of other pathways. Although there have been advances in symptomatic treatment, ALS remains an incurable condition. Advances in ALS management prolong survival but simultaneously raise challenging ethical dilemmas for physicians, patients and their families. Here, we review current practice in the management of ALS including pharmacological treatment, nutritional management, respiratory care, and evolving strategies in the management of cognitive impairment.
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Affiliation(s)
- Julie Phukan
- Dept. of Neurology, Beaumont Hospital, and Trinity College Institute of Neuroscience, Dublin 9, Ireland
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Sonoo M, Kuwabara S, Shimizu T, Komori T, Hirashima F, Inaba A, Hatanaka Y, Misawa S, Kugio Y. Utility of trapezius EMG for diagnosis of amyotrophic lateral sclerosis. Muscle Nerve 2009; 39:63-70. [DOI: 10.1002/mus.21196] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Hong YH, Sung JJ, Kim SM, Park KS, Lee KW, Chang KH, Song IC. Diffusion Tensor Tractography-based Analysis of the Pyramidal Tract in Patients with Amyotrophic Lateral Sclerosis. J Neuroimaging 2008; 18:282-7. [DOI: 10.1111/j.1552-6569.2007.00153.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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41
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Schmied A, Attarian S. Enhancement of single motor unit inhibitory responses to transcranial magnetic stimulation in amyotrophic lateral sclerosis. Exp Brain Res 2008; 189:229-42. [PMID: 18496679 DOI: 10.1007/s00221-008-1420-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2007] [Accepted: 05/02/2008] [Indexed: 12/11/2022]
Abstract
In healthy human subjects, transcranial magnetic stimulation (TMS) applied to the motor cortex induces concurrent inhibitory and excitatory effects on motoneurone activity. In amyotrophic lateral sclerosis (ALS), a neurodegenerative disease affecting both cortical and spinal motor neurons, paired-pulse studies based on electromyographic (EMG) recording have revealed a decrease in TMS-induced inhibition. This suggested that inhibition loss may promote excito-toxicity in this disease. Against this hypothesis, an abnormally high incidence of inhibitory responses to TMS has been observed in the peristimulus time histograms (PSTHs) in ALS single motor unit studies. The disappearance of cortico-motoneuronal excitatory inputs might, however, have facilitated the detection of single motor unit inhibitory responses in the PSTHs. This question was addressed here using a new approach, where the strength of the excitatory and inhibitory effects of TMS on motoneurone activity was assessed from the duration of inter-spike intervals (ISIs). This analysis was conducted on single motor unit (MU), tested on healthy subjects and patients with ALS or Kennedy's disease (KD), a motor neuron disease which unlike ALS, spares the cortico-spinal pathway. MUs tested on KD patients behaved like those of healthy subjects unlike those tested on ALS patients. The present data reveal that in ALS, the TMS-induced inhibitory effects are truly enhanced during voluntary contractions and not reduced, as observed in paired-pulse TMS studies under resting conditions. The possible contribution of inhibitory loss to the physiopathology of ALS therefore needs to be reconsidered. The present data do not support the idea that inhibition loss may underlie excito-toxicity in ALS.
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Affiliation(s)
- Annie Schmied
- Plasticity and Physiopathology of Movement, P3M, UMR 6196, CNRS, University Aix-Marseilles II, 31 Chemin Joseph Aiguier, 13402 Marseilles Cedex 20, France.
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42
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Visser J, de Visser M, Van den Berg-Vos RM, Van den Berg LH, Wokke JHJ, de Jong JMBV, Franssen H. Interpretation of electrodiagnostic findings in sporadic progressive muscular atrophy. J Neurol 2008; 255:903-9. [DOI: 10.1007/s00415-008-0813-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2007] [Revised: 10/18/2007] [Accepted: 11/09/2007] [Indexed: 10/22/2022]
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43
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Yin H, Cheng SHT, Zhang J, Ma L, Gao Y, Li D, Lim CCT. Corticospinal Tract Degeneration in Amyotrophic Lateral Sclerosis: A Diffusion Tensor Imaging and Fibre Tractography Study. Ann Acad Med Singap 2008. [DOI: 10.47102/annals-acadmedsg.v37n5p411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Motor neuron damage and cortical spinal tract (CST) degeneration in amyotrophic lateral sclerosis (ALS) are difficult to visualise and quantify on conventional magnetic resonance imaging (MRI).
Clinical Picture: We studied 8 ALS patients and 12 normal volunteers using diffusion tensor imaging (DTI) and fibre tractography using fibre assignment by continuous tracking (FACT) to study the fibres of the CST and the posterior thalamic radiation (PTR), a non-motor tract.
Outcome: Fibre tractography was successfully performed in all normal volunteers and all patients except 1. The fibre bundles of the CST, but not the PTR, were significantly reduced (P<0.05) in patients compared to normal volunteers.
Conclusion: Fibre tractography can visualise axonal degeneration in the CST and may provide supplementary information about upper motor neuron disease in ALS patients.
Key words: Amyltrophic lateral sclerosis, Diffusion-weighted imaging, Echo planar imaging, Fibre tractography, Magnetic resonance imaging
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Affiliation(s)
- Hong Yin
- National Neuroscience Institute, Singapore
| | | | | | - Lin Ma
- Chinese PLA General Hospital, Beijing, China
| | - Yuangui Gao
- Chinese PLA General Hospital, Beijing, China
| | - Dejun Li
- Chinese PLA General Hospital, Beijing, China
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de Carvalho M, Dengler R, Eisen A, England JD, Kaji R, Kimura J, Mills K, Mitsumoto H, Nodera H, Shefner J, Swash M. Electrodiagnostic criteria for diagnosis of ALS. Clin Neurophysiol 2007; 119:497-503. [PMID: 18164242 DOI: 10.1016/j.clinph.2007.09.143] [Citation(s) in RCA: 770] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2007] [Revised: 09/19/2007] [Accepted: 09/22/2007] [Indexed: 12/13/2022]
Abstract
A consensus meeting was held to determine the best use and interpretation of electrophysiological data in the diagnosis of ALS. The utility of needle EMG and nerve conduction studies was affirmed. It is recommended that electrophysiological evidence for chronic neurogenic change should be taken as equivalent to clinical information in the recognition of involvement of individual muscles in a limb. In addition, in the context of a suspected clinical diagnosis of ALS, fasciculation potentials should be taken as equivalent to fibrillation potentials and positive sharp waves in recognising denervation. The importance of searching for instability in fasciculation potentials and in motor unit potentials in ALS is stressed. These changes in the interpretation of electrophysiological data render obsolete the category Probable Laboratory-Supported ALS in the modified El Escorial diagnostic criteria for ALS. Methods for detection of upper motor neuron abnormality appear sensitive but require further study, particularly regarding their value when clinical signs of upper motor neuron lesion are uncertain.
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Affiliation(s)
- Mamede de Carvalho
- Department of Neurology, Hospital de Santa Maria, University of Lisbon, Lisbon, Portugal
| | - Reinhard Dengler
- Department of Neurology, Medizinische Hochschule Hannover, Germany
| | - Andrew Eisen
- Department of Neurology, University of British Columbia, Vancouver, Canada
| | - John D England
- Department of Neurology, Billings Clinic, Billings, MT, USA
| | - Ryuji Kaji
- Department of Neurology, Tokushima University Graduate School of Medicine, Tokushima-city, Japan
| | - Jun Kimura
- Department of Neurology, University of Iowa, Iowa City, USA
| | - Kerry Mills
- Department of Neurology, Kings College Hospital, Guys Kings and St. Thomas's School of Medicine, London, UK
| | - Hiroshi Mitsumoto
- Eleanor and Lou Gehrig ALS Center, Neurological Institute, Columbia University, NY, USA
| | - Hiroyuki Nodera
- Department of Neurology, Tokushima University, Tokushima-city, Japan
| | - Jeremy Shefner
- Department of Neurology, Upstate Medical University, Syracuse, NY, USA
| | - Michael Swash
- Department of Neurology, Royal London Hospital, Queen Mary University of London, London, UK.
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Abstract
To study the relative importance of upper motor neuron (UMN) dysfunction in the weakness of amyotrophic lateral sclerosis (ALS) and to compare the sensitivity of several transcranial magnetic stimulation (TMS) parameters as means of assessing UMN impairment in ALS, we used TMS to evaluate one upper limb of 63 patients. The triple-stimulation technique (TST) and silent period (SP) were found to be the most frequently abnormal parameters (55.6% and 47.6%, respectively), without significant difference in their diagnostic sensitivity. The SP was found to be a useful parameter in patients with suspected or possible ALS. A positive correlation was found between weakness and the TST amplitude ratio, indicating that weakness may partly be caused by UMN dysfunction. Thus, the TST provides a quantitative tool for assessing UMN conduction failure. When used in association with the SP, the TST provides a sensitive diagnostic tool for use on ALS patients.
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Affiliation(s)
- Shahram Attarian
- Department of Neurology and Neuromuscular Diseases, CHU La Timone, 264 rue Saint-Pierre, 13385 Marseille, France.
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Karandreas N, Papadopoulou M, Kokotis P, Papapostolou A, Tsivgoulis G, Zambelis T. Impaired interhemispheric inhibition in amyotrophic lateral sclerosis. ACTA ACUST UNITED AC 2007; 8:112-8. [PMID: 17453640 DOI: 10.1080/17482960601030113] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The pathogenesis of sporadic amyotrophic lateral sclerosis (ALS) remains unknown. Neurophysiological studies provide evidence of hyperexcitability of the motor cortex or of impairment of inhibitory intrahemispheric modulation of the corticomotoneuron in ALS. In this paper, we used TMS to elicit transcallosal inhibition of the motor cortex in ALS patients in order to investigate whether interhemispheric inhibitory mechanisms subserved by callosal fibres are also disturbed in ALS. Twenty-five patients with ALS and 18 controls were recruited for the study. Resting Motor Threshold (RMT), Silent Period (SP) and interhemispheric inhibition (IHI) were recorded. No significant difference was detected regarding RMT or the duration of SP between patients and controls. IHI was detected in all controls. IHI was totally absent in eight patients, in another eight patients IHI did not reach a significant level and in the remaining nine patients was normal. The degree of IHI was significantly lower in ALS patients than in controls (p = 0.001). In conclusion, altered IHI in ALS patients is in line with the general pattern of reduced corticomotoneuron inhibition, being thus, one of the factors which may lead to chronic overexcitation of pyramidal cells.
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Affiliation(s)
- Nikos Karandreas
- Laboratory of Electromyography and Clinical Neurophysiology, Aeginition Hospital, University of Athens, Greece.
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47
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Boe SG, Stashuk DW, Doherty TJ. Motor unit number estimates and quantitative motor unit analysis in healthy subjects and patients with amyotrophic lateral sclerosis. Muscle Nerve 2007; 36:62-70. [PMID: 17455264 DOI: 10.1002/mus.20784] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Limitations associated with global measures of function in patients with amyotrophic lateral sclerosis (ALS) and the qualitative nature of needle electromyography have stimulated the development of alternate means of monitoring disease severity and progression in ALS. Thus, the objective of this study was to examine the ability of one these techniques, decomposition-based quantitative electromyography (DQEMG), to obtain electrophysiological data, including motor unit number estimates (MUNEs), from a group of patients with ALS. The first dorsal interosseous and biceps brachii muscles were studied in 10 healthy subjects and 9 patients with ALS. Following the acquisition of a maximum M wave, needle- and surface-detected EMGs were collected simultaneously during 30-second contractions performed at 10% of the maximum voluntary contraction force to obtain motor unit potential (MUP) trains. DQEMG was then used to extract the surface-detected MUP associated with each MUP train, the mean size of which was divided into the maximum M wave to obtain a MUNE. The results suggest that quantitative electrophysiological data obtained using DQEMG are representative of the pathophysiological changes in the lower motor system in ALS patients, supporting its use in studies documenting the natural history and progression of the disease.
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Affiliation(s)
- Shaun G Boe
- School of Kinesiology, University of Western Ontario, London, Ontario, Canada.
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48
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Argyriou AA, Polychronopoulos P, Talelli P, Chroni E. F wave study in amyotrophic lateral sclerosis: Assessment of balance between upper and lower motor neuron involvement. Clin Neurophysiol 2006; 117:1260-5. [PMID: 16678483 DOI: 10.1016/j.clinph.2006.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2005] [Revised: 02/20/2006] [Accepted: 03/01/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to record significant F wave variable changes in ALS patients having no advanced disease. Furthermore, an interpretation of these F wave abnormalities in the context of upper (UMN) and lower motor neuron (LMN) dysfunction was attempted. METHODS Standard motor and sensory conduction study was performed to the ulnar nerves of 23 patients with ALS (13 males and 10 females with mean age 67.2+/-5.3 years), having a clinically predominant LMN syndrome. A series of 40 electrical stimuli were also delivered to both their ulnar nerves in order to obtain F waves. The following F wave variables were estimated: F persistence, F wave latency, amplitude, duration and F chronodispersion. Twenty-three, age-and gender-matched healthy volunteers served as controls. RESULTS Both the distal and proximal ulnar a-CMAPs (P=0.001) and the MCV (P=0.014) values were significantly decreased in patients, than the controls. The sensory conduction study was normal. The ulnar F wave persistence in the ALS patients was significantly lower than that of the controls (P=0.0007). The mean (P=0.0001), minimal (P=0.0001) and maximal (P=0.0001) F wave latencies were significantly prolonged, the F wave amplitudes (P=0.0001) were significantly higher and the F wave chronodispersion (P=0.014) was significantly increased in the patients than the controls. CONCLUSIONS Significant F wave abnormalities occur in patients with ALS, even those patients having no advanced disease. Increased F wave amplitudes combined with low persistence is a pattern consistent with ALS. SIGNIFICANCE Our results show that patients with ALS having predominantly LMN involvement also have electrophysiological UMN dysfunction.
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Affiliation(s)
- Andreas A Argyriou
- EMG Laboratory, Department of Neurology, The University of Patras Medical School, P.O. Box 1045, 26504 Rion-Patras, Greece
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49
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Abstract
Weakness is a characteristic of muscles influenced by the postpolio syndrome (PPS), amyotrophic lateral sclerosis (ALS), and spinal cord injury (SCI). The strength deficits relate to changes in muscle use and to the chronic denervation that can follow the spinal motoneuron death common to these disorders. PPS, ALS, and SCI also involve variable amounts of supraspinal neuron death, the effects of which on muscle weakness remains unclear. Nevertheless, weakness of muscle itself defines the functional consequences of these disorders. A weaker muscle requires an individual to work that muscle at higher than usual intensities relative to its maximal capacity, inducing progressive fatigue and an increased sense of effort. Little evidence is available to suggest that the fatigue commonly experienced by individuals with these disorders relates to an increase in the intrinsic fatigability of the muscle fibers. The only exception is when SCI induces chronic muscle paralysis. To reduce long-term functional deficits in these disorders, studies must identify the signaling pathways that influence neuron survival and determine the factors that encourage and limit sprouting of motor axons. This may ensure that a greater proportion of the fibers in each muscle remain innervated and available for use.
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Affiliation(s)
- Christine K Thomas
- The Miami Project to Cure Paralysis, Lois Pope LIFE Center, 1095 NW 14th Terrace (R-48), Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL 33136, USA.
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50
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Abstract
Motor neuron disease (MND) is characterised by progressive deterioration of the corticospinal tract, brainstem, and anterior horn cells of the spinal cord. There is no pathognomonic test for the diagnosis of MND, and physicians rely on clinical criteria-upper and lower motor neuron signs-for diagnosis. The presentations, clinical phenotypes, and outcomes of MND are diverse and have not been combined into a marker of disease progression. No single algorithm combines the findings of functional assessments and rating scales, such as those that assess quality of life, with biological markers of disease activity and findings from imaging and neurophysiological assessments. Here, we critically appraise developments in each of these areas and discuss the potential of such measures to be included in the future assessment of disease progression in patients with MND.
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Affiliation(s)
- Jennica M C Winhammar
- Department of Neurology and Multidisciplinary Motor Neurone Disease Clinic, Royal North Shore Hospital, NSW, Australia
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