1
|
Bjelica B, Bartels MB, Hesebeck-Brinckmann J, Petri S. Non-motor symptoms in patients with amyotrophic lateral sclerosis: current state and future directions. J Neurol 2024; 271:3953-3977. [PMID: 38805053 PMCID: PMC11233299 DOI: 10.1007/s00415-024-12455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/14/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease characterized by the progressive degeneration of both upper and lower motor neurons. A defining histopathological feature in approximately 97% of all ALS cases is the accumulation of phosphorylated trans-activation response (TAR) DNA-binding protein 43 protein (pTDP-43) aggregates in the cytoplasm of neurons and glial cells within the central nervous system. Traditionally, it was believed that the accumulation of TDP-43 aggregates and subsequent neurodegeneration primarily occurs in motor neurons. However, contemporary evidence suggests that as the disease progresses, other systems and brain regions are also affected. Despite this, there has been a limited number of clinical studies assessing the non-motor symptoms in ALS patients. These studies often employ various outcome measures, resulting in a wide range of reported frequencies of non-motor symptoms in ALS patients. The importance of assessing the non-motor symptoms reflects in a fact that they have a significant impact on patients' quality of life, yet they frequently go underdiagnosed and unreported during clinical evaluations. This review aims to provide an up-to-date overview of the current knowledge concerning non-motor symptoms in ALS. Furthermore, we address their diagnosis and treatment in everyday clinical practice.
Collapse
Affiliation(s)
- Bogdan Bjelica
- Department of Neurology, Hannover Medical School, 1, Carl-Neuberg-Strasse, 30625, Hannover, Germany.
| | - Maj-Britt Bartels
- Precision Neurology of Neuromuscular and Motoneuron Diseases, University of Luebeck, Lübeck, Germany
| | - Jasper Hesebeck-Brinckmann
- Neurology Department, Division for Neurodegenerative Diseases, University Medicine Mannheim, Heidelberg University, Mannheim Center for Translational Medicine, Mannheim, Germany
| | - Susanne Petri
- Department of Neurology, Hannover Medical School, 1, Carl-Neuberg-Strasse, 30625, Hannover, Germany
| |
Collapse
|
2
|
Pota V, Sansone P, De Sarno S, Aurilio C, Coppolino F, Barbarisi M, Barbato F, Fiore M, Cosenza G, Passavanti MB, Pace MC. Amyotrophic Lateral Sclerosis and Pain: A Narrative Review from Pain Assessment to Therapy. Behav Neurol 2024; 2024:1228194. [PMID: 38524401 PMCID: PMC10960655 DOI: 10.1155/2024/1228194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 02/11/2024] [Accepted: 03/06/2024] [Indexed: 03/26/2024] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is the most frequent neurodegenerative disease of the motor system that affects upper and lower motor neurons, leading to progressive muscle weakness, spasticity, atrophy, and respiratory failure, with a life expectancy of 2-5 years after symptom onset. In addition to motor symptoms, patients with ALS have a multitude of nonmotor symptoms; in fact, it is currently considered a multisystem disease. The purpose of our narrative review is to evaluate the different types of pain, the correlation between pain and the disease's stages, the pain assessment tools in ALS patients, and the available therapies focusing above all on the benefits of cannabis use. Pain is an underestimated and undertreated symptom that, in the last few years, has received more attention from research because it has a strong impact on the quality of life of these patients. The prevalence of pain is between 15% and 85% of ALS patients, and the studies on the type and intensity of pain are controversial. The absence of pain assessment tools validated in the ALS population and the dissimilar study designs influence the knowledge of ALS pain and consequently the pharmacological therapy. Several studies suggest that ALS is associated with changes in the endocannabinoid system, and the use of cannabis could slow the disease progression due to its neuroprotective action and act on pain, spasticity, cramps, sialorrhea, and depression. Our research has shown high patients' satisfaction with the use of cannabis for the treatment of spasticity and related pain. However, especially due to the ethical problems and the lack of interest of pharmaceutical companies, further studies are needed to ensure the most appropriate care for ALS patients.
Collapse
Affiliation(s)
- Vincenzo Pota
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Pasquale Sansone
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Sara De Sarno
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Caterina Aurilio
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Francesco Coppolino
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Manlio Barbarisi
- Multidisciplinary Department of Medical, Surgical and Dental Specialties, University of Campania “L. Vanvitelli”, Naples, Italy
| | | | - Marco Fiore
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Gianluigi Cosenza
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Maria Beatrice Passavanti
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| | - Maria Caterina Pace
- Department of Women, Child, General and Specialistic Surgery, University of Campania “L. Vanvitelli”, Naples, Italy
| |
Collapse
|
3
|
Seki S, Kitaoka Y, Kawata S, Nishiura A, Uchihashi T, Hiraoka SI, Yokota Y, Isomura ET, Kogo M, Tanaka S. Characteristics of Sensory Neuron Dysfunction in Amyotrophic Lateral Sclerosis (ALS): Potential for ALS Therapy. Biomedicines 2023; 11:2967. [PMID: 38001967 PMCID: PMC10669304 DOI: 10.3390/biomedicines11112967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating neurodegenerative disorder characterised by the progressive degeneration of motor neurons, resulting in muscle weakness, paralysis, and, ultimately, death. Presently, no effective treatment for ALS has been established. Although motor neuron dysfunction is a hallmark of ALS, emerging evidence suggests that sensory neurons are also involved in the disease. In clinical research, 30% of patients with ALS had sensory symptoms and abnormal sensory nerve conduction studies in the lower extremities. Peroneal nerve biopsies show histological abnormalities in 90% of the patients. Preclinical research has reported several genetic abnormalities in the sensory neurons of animal models of ALS, as well as in motor neurons. Furthermore, the aggregation of misfolded proteins like TAR DNA-binding protein 43 has been reported in sensory neurons. This review aims to provide a comprehensive description of ALS-related sensory neuron dysfunction, focusing on its clinical changes and underlying mechanisms. Sensory neuron abnormalities in ALS are not limited to somatosensory issues; proprioceptive sensory neurons, such as MesV and DRG neurons, have been reported to form networks with motor neurons and may be involved in motor control. Despite receiving limited attention, sensory neuron abnormalities in ALS hold potential for new therapies targeting proprioceptive sensory neurons.
Collapse
Affiliation(s)
- Soju Seki
- Department of Oral and Maxillofacial Surgery, Graduate School of Dentistry, Osaka University, 1-8 Yamadaoka, Suita 565-0871, Osaka, Japan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Sensory Involvement in Amyotrophic Lateral Sclerosis. Int J Mol Sci 2022; 23:ijms232415521. [PMID: 36555161 PMCID: PMC9779879 DOI: 10.3390/ijms232415521] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/19/2022] [Accepted: 12/03/2022] [Indexed: 12/13/2022] Open
Abstract
Although amyotrophic lateral sclerosis (ALS) is pre-eminently a motor disease, the existence of non-motor manifestations, including sensory involvement, has been described in the last few years. Although from a clinical perspective, sensory symptoms are overshadowed by their motor manifestations, this does not mean that their pathological significance is not relevant. In this review, we have made an extensive description of the involvement of sensory and autonomic systems described to date in ALS, from clinical, neurophysiological, neuroimaging, neuropathological, functional, and molecular perspectives.
Collapse
|
5
|
Ozturk R, Karlsson P, Hu X, Akdeniz E, Surucu S, Isak B. Stereological and electrophysiological evaluation of autonomic involvement in amyotrophic lateral sclerosis. Neurophysiol Clin 2022; 52:446-458. [PMID: 36155704 DOI: 10.1016/j.neucli.2022.08.003] [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: 01/24/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Previous studies have identified autonomic dysfunction in amyotrophic lateral sclerosis (ALS) using mostly neurophysiological techniques. In this study, stereological evaluation of autonomic fibers and sweat glands has been performed to identify structural evidence of autonomic denervation in patients with ALS. METHODS In this study, 29 ALS patients were compared to 29 controls using COMPASS-31 questionnaire, sympathetic skin response (SSR), and heart rate variability (HRV) at rest. From the same cohorts, 20 ALS patients and 15 controls were further evaluated using staining of autonomic nerve fibers and sweat glands in skin biopsies. SSR and resting HRV were repeated in the ALS patient cohort one year later. RESULTS COMPASS-31 total score, gastrointestinal- and urinary-sub scores were higher in ALS patients than controls (P = 0.004, P = 0.005, and P = 0.049, respectively). In the ALS patient cohort, SSR amplitudes in hands and feet were lower than in controls (P<0.0001 and P = 0.0009, respectively), but there was no difference in resting HRV (P>0.05). While there was no change in nerve fibers innervating sweat glands, their density was lower in ALS patients than controls, and semi-quantitative analysis also showed structural damage (P = 0.02 and P = 0.001, respectively). SSR and resting HRV of ALS patients remained stable during the one-year follow-up period (P>0.05). DISCUSSION Supporting abnormal neurophysiological tests, stereological analysis revealed direct evidence of autonomic denervation in ALS patients. However, the degenerative process in autonomic nerve fibers is relatively slow, compared to the rate of motor neuron degeneration in this condition.
Collapse
Affiliation(s)
- Rustem Ozturk
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey.
| | - Pall Karlsson
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Xiaoli Hu
- Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Esra Akdeniz
- Department of Medical Education, School of Medicine, Marmara University Hospital, Istanbul, Turkey
| | - Selcuk Surucu
- Department of Anatomy, Faculty of Medicine, Koç University, Istanbul, Turkey
| | - Baris Isak
- Department of Neurology, Marmara University Hospital, Istanbul, Turkey
| |
Collapse
|
6
|
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] [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.
Collapse
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.
| |
Collapse
|
7
|
Phenotypic and molecular diversities of spinocerebellar ataxia type 2 in Japan. J Neurol 2021; 268:2933-2942. [PMID: 33625581 DOI: 10.1007/s00415-021-10467-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/27/2021] [Accepted: 02/11/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND We intended to clarify the phenotypic and molecular diversities of spinocerebellar ataxia type 2 (SCA2) in Japan. METHODS DNA was extracted from the peripheral blood of 436 patients, including 126 patients with chronic neuropathy, 108 with amyotrophic lateral sclerosis, and 202 with cerebellar ataxia. We then PCR-amplified and sequenced the ATXN2 gene. The biopsied sural nerves of mutation-positive patients were subjected to light-microscopic and electron-microscopic analyses. Transfection analyses were performed using a Schwann cell line, IMS32. RESULTS We found PCR-amplified products potentially corresponding to expanded CAG repeats in four patients. Two patients in the chronic neuropathy group had a full repeat expansion or an intermediate expansion (39 or 32 repeats), without limb ataxia. The sural nerve biopsy findings of the two patients included axonal neuropathy and mixed neuropathy (axonal changes with demyelination). Schwann cells harbored either cytoplasmic or nuclear inclusions on electron microscopic examination. Both patients recently exhibited pyramidal signs. In the third patient in the cerebellar ataxia group, we identified a novel 21-base duplication mutation near 22 CAG repeats (c.432_452dup). The transfection study revealed that the 21-base-duplication mutant Ataxin-2 proteins aggregated in IMS32 and rendered cells susceptible to oxidative stress, similar to a CAG-expanded mutant. The fourth patient, with 41 repeats, had ataxia and spasticity. The two patients with cerebellar ataxia also had peripheral neuropathy. CONCLUSIONS Patients with expanded CAG repeats can exhibit a neuropathy-dominant phenotype not described previously. The novel 21-base-duplication mutant seems to share the aggregation properties of polyglutamine-expanded mutants.
Collapse
|
8
|
Cengiz B, Fidancı H, Baltacı H, Türksoy E, Kuruoğlu R. Reduced Occipital Cortex Excitability in Amyotrophic Lateral Sclerosis. J Clin Neurophysiol 2021; 39:486-491. [PMID: 33443392 DOI: 10.1097/wnp.0000000000000805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE In addition to motor cortex involvement, sensory abnormalities have been demonstrated in amyotrophic lateral sclerosis (ALS), including structural and metabolic alterations in the occipital cortex. The aim of this study was to examine occipital excitability changes in ALS. METHODS Twenty-one patients with ALS and 16 healthy subjects were enrolled into the study. Phosphene experience and phosphene threshold were studied to assess occipital excitability. Cognitive function was evaluated in both groups by means of Montreal Cognitive Assessment and Addenbrooke's Cognitive Examination-Revised visuospatial score tests. RESULTS Phosphene was experienced in 13 (81.3%) healthy subjects and 9 (42.9%) patients with ALS (P = 0.04). The mean phosphene threshold was not significantly different between the two groups. No correlation existed between phosphene threshold and motor cortical excitability parameters, ALS Functional Rating Scale Revised, Montreal Cognitive Assessment, and Addenbrooke's Cognitive Examination-Revised scores. CONCLUSIONS Visual cortex is affected, and the occipital excitability is reduced in ALS, without any relation to motor cortical excitability changes, providing another clue suggestive of sensory involvement in ALS.
Collapse
Affiliation(s)
- Bülent Cengiz
- Department of Neurology, Gazi University Faculty of Medicine, Ankara, Turkey; and Division of Clinical Neurophysiology, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | | | | | | |
Collapse
|
9
|
Impaired pain processing and its association with attention disturbance in patients with amyotrophic lateral sclerosis. Neurol Sci 2021; 42:3327-3335. [PMID: 33398509 DOI: 10.1007/s10072-020-05028-7] [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: 10/09/2020] [Accepted: 12/23/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Cognitive dysfunction characterized by executive dysfunction and persistent attention function has been reported in patients with amyotrophic lateral sclerosis (ALS); however, it is unclear if this contributes to the pain processing deficits associated with the disease. OBJECTIVE We clarified the relationship between pain processing and both cognitive function and sensory symptoms in patients with ALS. METHODS We enrolled 23 patients with ALS and 14 healthy control subjects. We examined pain-related somatosensory evoked potentials (SEPs) using an intra-epidermal needle electrode. We evaluated cognitive function and the clinical characteristics of sensation and analyzed their relationships with pain-related SEPs. RESULTS Pain-related SEP amplitudes were significantly lower, while the rate of amplitude attenuation due to habituation or change in attention was significantly greater in patients with ALS than in control subjects. There were no significant differences in pain-related SEP parameters between patients with or without sensory symptoms. Instead, pain-related SEP amplitude and its rate of attenuation were correlated with cognitive dysfunction, particularly with attention domains. CONCLUSIONS Our results suggest that attention deficit, but not sensory nerve involvement, is a major cause of the alterations in pain-related SEP in patients with ALS.
Collapse
|
10
|
Yuan Y, Liu Z, Hou X, Li W, Ni J, Huang L, Hu Y, Liu P, Hou X, Xue J, Sun Q, Tian Y, Jiao B, Duan R, Jiang H, Shen L, Tang B, Wang J. Identification of GGC repeat expansion in the NOTCH2NLC gene in amyotrophic lateral sclerosis. Neurology 2020; 95:e3394-e3405. [PMID: 32989102 DOI: 10.1212/wnl.0000000000010945] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To determine whether the GGC repeats in the NOTCH2NLC gene contribute to amyotrophic lateral sclerosis (ALS). METHODS In this study, 545 patients with ALS and 1,305 healthy controls from mainland China were recruited. Several pathogenic mutations in known ALS-causative genes (including C9ORF72 and ATXN2) and polynucleotide repeat expansions in NOP56 and AR genes were excluded. Repeat-primed PCR and GC-rich PCR were performed to determine the GGC repeat size in NOTCH2NLC. Systematic and targeted clinical evaluations and investigations, including skin biopsy and dynamic electrophysiologic studies, were conducted in the genetically affected patients. RESULTS GGC repeat expansion was observed in 4 patients (numbers of repeats 44, 54, 96, and 143), accounting for ≈0.73% (4 of 545) of all patients with ALS. A comparison with 1,305 healthy controls revealed that GGC repeat expansion in NOTCH2NLC was associated with ALS (Fisher exact test, 4 of 545 vs 0 of 1,305, p = 0.007). Compared to patients with the neuronal intranuclear inclusion disease (NIID) muscle weakness-dominant subtype, patients with ALS phenotype carrying the abnormal repeat expansion tended to have a severe phenotype and rapid deterioration. CONCLUSION Our results suggest that ALS is a specific phenotype of NIID or that GGC expansion in NOTCH2NLC is a factor that modifies ALS. These findings may help clarify the pathogenic mechanism of ALS and may expand the known clinical spectrum of NIID.
Collapse
Affiliation(s)
- Yanchun Yuan
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Zhen Liu
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Xuan Hou
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Wanzhen Li
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China.
| | - Jie Ni
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Ling Huang
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Yiting Hu
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Pan Liu
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Xiaorong Hou
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Jin Xue
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Qiying Sun
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Yun Tian
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Bin Jiao
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Ranhui Duan
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Hong Jiang
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Lu Shen
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Beisha Tang
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China
| | - Junling Wang
- From the Department of Neurology (Y.Y., Z.L., X.H., W.L., J.N., Y.H., P.L., X.H., Q.S., Y.T., B.J., H.J., L.S, B.T., J.W.) and National Clinical Research Center for Geriatric Diseases (H.J., L.S, B.T., J.W.), Xiangya Hospital, Department of Neurology (L.H.), the Third Xiangya Hospital, Laboratory of Medical Genetics (J.X., R.D., H.J., L.S, B.T., J.W.), and Key Laboratory of Hunan Province in Neurodegenerative Disorders (J.H., L.S, B.T., J.W.), Central South University, Changsha, Hunan, PR China.
| |
Collapse
|
11
|
Riancho J, Paz-Fajardo L, López de Munaín A. Clinical and preclinical evidence of somatosensory involvement in amyotrophic lateral sclerosis. Br J Pharmacol 2020; 178:1257-1268. [PMID: 32673410 DOI: 10.1111/bph.15202] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/01/2020] [Accepted: 07/12/2020] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is the most common motor neuron neurodegenerative disease. Although it has been classically considered as a disease limited to the motor system, there is increasing evidence for the involvement of other neural and non-neuronal systems. In this review, we will discuss currently existing literature regarding the involvement of the sensory system in ALS. Human studies have reported intradermic small fibre loss, sensory axonal predominant neuropathy, as well as somatosensory cortex hyperexcitability. In line with this, ALS animal studies have demonstrated the involvement of several sensory components. Specifically, they have highlighted the impairment of sensory-motor networks as a potential mechanism for the disease. The elucidation of these "non-motor" systems involvement, which might also be part of the degeneration process, should prompt the scientific community to re-consider ALS as a pure motor neuron disease, which may in turn result in more holistic research approaches. LINKED ARTICLES: This article is part of a themed issue on Neurochemistry in Japan. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.6/issuetoc.
Collapse
Affiliation(s)
- Javier Riancho
- Service of Neurology, Hospital Sierrallana-IDIVAL, Torrelavega, Spain.,Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain.,Centro de Investigación en Red de Enfermedades Neurodegenerativas, CIBERNED, Instituto Carlos III, Madrid, Spain
| | - Lucía Paz-Fajardo
- Service of Internal Medicine, Hospital Sierrallana-IDIVAL, Torrelavega, Spain
| | - Adolfo López de Munaín
- Centro de Investigación en Red de Enfermedades Neurodegenerativas, CIBERNED, Instituto Carlos III, Madrid, Spain.,Neurosciences Area, Biodonostia Research Institute, San Sebastián, Spain.,Neurology Department, Donostia University Hospital-OSAKIDETZA, San Sebastián, Spain.,Neurosciences Department, Basque Country University, San Sebastián, Spain
| |
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW In amyotrophic lateral sclerosis (ALS), sleep disruption is frequently present and substantially adds to disease burden. This review aims to summarize current knowledge on causes, pathophysiology, and treatment of sleep disturbances in ALS. RECENT FINDINGS Motor neuron degeneration and muscle weakness may lead to muscle cramps, pain, spasticity, immobilization, restless legs, sleep-disordered breathing, and difficulties to clear secretions. Furthermore, existential fears and depression may promote insomnia. Sleep-disordered breathing, and nocturnal hypoventilation in particular, requires ventilatory support which meaningfully prolongs survival and improves health-related quality of life albeit respiratory failure is inevitable. Early indication for non-invasive ventilation can be achieved by inclusion of capnometry in diagnostic sleep studies. Sleep disruption is extremely common in ALS and may arise from different etiologies. The absence of causative therapeutic options for ALS underlines the importance of symptomatic and palliative treatment strategies that acknowledge sleep-related complaints.
Collapse
Affiliation(s)
- Matthias Boentert
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster (UKM), Albert-Schweitzer-Campus 1, Building A1, 48149, Münster, Germany.
- Department of Medicine, UKM Marienhospital Steinfurt, Steinfurt, Germany.
| |
Collapse
|
13
|
A nerve conduction study predicts the prognosis of sporadic amyotrophic lateral sclerosis. J Neurol 2020; 267:2524-2532. [PMID: 32367295 DOI: 10.1007/s00415-020-09858-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/19/2020] [Accepted: 04/22/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To clarify the relationship between nerve conduction study (NCS) and prognosis in patients with amyotrophic lateral sclerosis (ALS). METHODS We included 190 patients with sporadic ALS. We used onset age, sex, onset site (bulbar vs. spinal), revised El Escorial criteria category (definite vs. others), and the King's clinical systems, and the Milano-Torino (MiToS) functional staging systems, and decline rates of revised ALS functional rating scale (ALSFRS-R) as known prognostic factors. An NCS was performed on the median, ulnar, tibial, and sural nerves. The endpoint was death or the introduction of tracheostomy positive-pressure ventilation. Multivariate analysis for each NCS variable, known prognostic factors was performed using Cox stepwise proportional hazards analysis. Univariate analysis was performed for NCS variables that showed a significant association with prognosis in multivariate analysis. Survival was analyzed with a Kaplan-Meier curve and log-rank test. RESULTS The Cox model identified the compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) amplitudes of the median nerve as prognostic factors. In the log-rank test, patients with higher median nerve CMAP amplitude had a significantly better prognosis than those with lower amplitude, regardless of age. And prognosis was better in the group with lower median nerve SNAP amplitude only in patients younger than the 25th percentile (~ 57 years). CONCLUSIONS CMAP and SNAP amplitudes of the median nerve are considered to be independent prognostic factors of sporadic ALS.
Collapse
|
14
|
Howells J, Sangari S, Matamala JM, Kiernan MC, Marchand-Pauvert V, Burke D. Interrogating interneurone function using threshold tracking of the H reflex in healthy subjects and patients with motor neurone disease. Clin Neurophysiol 2020; 131:1986-1996. [PMID: 32336595 DOI: 10.1016/j.clinph.2020.03.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 02/21/2020] [Accepted: 03/15/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The excitability of the lower motoneurone pool is traditionally tested using the H reflex and a constant-stimulus paradigm, which measures changes in the amplitude of the reflex response. This technique has limitations because reflex responses of different size must involve the recruitment or inhibition of different motoneurones. The threshold-tracking technique ensures that the changes in excitability occur for an identical population of motoneurones. We aimed to assess this technique and then apply it in patients with motor neurone disease (MND). METHODS The threshold-tracking approach was assessed in 17 healthy subjects and 11 patients with MND. The soleus H reflex was conditioned by deep peroneal nerve stimulation producing reciprocal Ia and so-called D1 and D2 inhibitions, which are believed to reflect presynaptic inhibition of soleus Ia afferents. RESULTS Threshold tracking was quicker than the constant-stimulus technique and reliable, properties that may be advantageous for clinical studies. D1 inhibition was significantly reduced in patients with MND. CONCLUSIONS Threshold tracking is useful and may be preferable under some conditions for studying the excitability of the motoneurone pool. The decreased D1 inhibition in the patients suggests that presynaptic inhibition may be reduced in MND. SIGNIFICANCE Reduced presynaptic inhibition could be evidence of an interneuronopathy in MND. It is possible that the hyperreflexia is a spinal pre-motoneuronal disorder, and not definitive evidence of corticospinal involvement in MND.
Collapse
Affiliation(s)
- James Howells
- Brain & Mind Centre, The University of Sydney, N.S.W. 2006, Australia
| | - Sina Sangari
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, LIB, F-75006 Paris, France
| | - José Manuel Matamala
- Department of Neurological Science and Biomedical Neuroscience Institute, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Matthew C Kiernan
- Brain & Mind Centre, The University of Sydney, N.S.W. 2006, Australia; Department of Neurology, Royal Prince Alfred Hospital and The University of Sydney, N.S.W. 2006, Australia
| | | | - David Burke
- Department of Neurology, Royal Prince Alfred Hospital and The University of Sydney, N.S.W. 2006, Australia.
| |
Collapse
|
15
|
Taga A, Schito P, Trapasso MC, Zinno L, Pavesi G. Pain at the onset of Amyotrophic Lateral Sclerosis: a cross-sectional study. Clin Neurol Neurosurg 2019; 186:105540. [PMID: 31634749 DOI: 10.1016/j.clineuro.2019.105540] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 09/18/2019] [Accepted: 09/28/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We evaluated ALS patients reporting pain, either generalized or localized, at disease onset and determined whether this feature defined a specific ALS phenotype. PATIENTS AND METHODS We considered all consecutive ALS patients referred to our Motor Neuron Diseases Center between 2006 and 2016 and included only patients who fulfilled the El Escorial revised criteria for probable and definite ALS diagnosis. We then identified those cases who reported pain at disease onset and compared them to all remaining cases. Secondary causes of pain have been excluded. RESULTS Our initial sample consisted of 108 patients (55 men and 53 women). We identified 5 cases with generalized pain and 16 cases with localized pain at disease onset, corresponding to 4.6% and 14.8% of the initial sample, respectively. Cases with generalized pain were all female and had an earlier disease onset (49.6 ± 1.5 vs 66.6 ± 10.2 yrs, p = 0.002). Cases with localized pain showed a preponderance of upper motor neuron symptoms/signs at disease onset. Patients with pain, either localized or generalized, had a significantly higher involvement of the limbs (82.6% vs 100%, p = 0.022), while the bulbar district was spared at disease onset (17.4% vs 0%, p = 0.008). More specifically, the proximal upper and distal lower limbs were more frequently affected by ALS in patients with pain at disease onset. In two cases, the clinical presentation was notable for the resemblance with complex regional pain syndrome. CONCLUSION The presence of pain at disease onset seems to relate to peculiar clinical features of ALS and may be pathophysiologically associated with neurodegeneration.
Collapse
Affiliation(s)
- Arens Taga
- Department of Neurology, Johns Hopkins University, 855 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Paride Schito
- Università degli Studi di Parma, Via Università 12, 43121, Parma, Italy
| | - Maria Claudia Trapasso
- Dipartimento di Emergenza-Urgenza, ed Area Medica Generale e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Lucia Zinno
- Dipartimento di Emergenza-Urgenza, ed Area Medica Generale e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| | - Giovanni Pavesi
- Dipartimento di Emergenza-Urgenza, ed Area Medica Generale e Specialistica, Azienda Ospedaliero-Universitaria di Parma, Via Gramsci 14, 43126, Parma, Italy
| |
Collapse
|
16
|
Boentert M. Sleep disturbances in patients with amyotrophic lateral sclerosis: current perspectives. Nat Sci Sleep 2019; 11:97-111. [PMID: 31496852 PMCID: PMC6701267 DOI: 10.2147/nss.s183504] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/16/2019] [Indexed: 01/08/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a progressive motor neuron disease inevitably leading to generalized muscle weakness and premature death. Sleep disturbances are extremely common in patients with ALS and substantially add to the burden of disease for both patients and caregivers. Disruption of sleep can be caused by physical symptoms, such as muscle cramps, pain, reduced mobility, spasticity, mucus retention, and restless legs syndrome. In addition, depression and anxiety may lead to significant insomnia. In a small subset of patients, rapid eye movement (REM) sleep behavioral disorder may be present, reflecting neurodegeneration of central nervous system pathways which are involved in REM sleep regulation. With regard to overall prognosis, sleep-disordered breathing (SDB) and nocturnal hypoventilation (NH) are of utmost importance, particularly because NH precedes respiratory failure. Timely mechanical ventilation is one of the most significant therapeutic measures to prolong life span in ALS, and transcutaneous capnometry is superior to pulse oxymetry to detect NH early. In addition, it has been shown that in patients on home ventilatory support, survival time depends on whether normocapnia, normoxia, and elimination of apneic events during sleep can be reliably achieved. Several studies have investigated sleep patterns and clinical determinants of sleep disruption in ALS, but exact prevalence numbers are unknown. Thus, constant awareness for sleep-related symptoms is appropriate. Since no curative treatment can be offered to affected patients, sleep complaints should be thoroughly investigated in order to identify any treatable etiology and improve or stabilize quality of life as much as possible. The use of hypnotics should be confined to palliation during the terminal phase and refractory insomnia in earlier stages of the disease, taking into account that most compounds potentially aggravate SDB.
Collapse
Affiliation(s)
- Matthias Boentert
- Department of Neurology, University Hospital Muenster, Muenster, Germany
| |
Collapse
|
17
|
Gentile F, Scarlino S, Falzone YM, Lunetta C, Tremolizzo L, Quattrini A, Riva N. The Peripheral Nervous System in Amyotrophic Lateral Sclerosis: Opportunities for Translational Research. Front Neurosci 2019; 13:601. [PMID: 31293369 PMCID: PMC6603245 DOI: 10.3389/fnins.2019.00601] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/27/2019] [Indexed: 12/11/2022] Open
Abstract
Although amyotrophic lateral sclerosis (ALS) has been considered as a disorder of the motor neuron (MN) cell body, recent evidences show the non-cell-autonomous pathogenic nature of the disease. Axonal degeneration, loss of peripheral axons and destruction of nerve terminals are early events in the disease pathogenic cascade, anticipating MN degeneration, and the onset of clinical symptoms. Therefore, although ALS and peripheral axonal neuropathies should be differentiated in clinical practice, they also share damage to common molecular pathways, including axonal transport, RNA metabolism and proteostasis. Thus, an extensive evaluation of the molecular events occurring in the peripheral nervous system (PNS) could be fundamental to understand the pathogenic mechanisms of ALS, favoring the discovery of potential disease biomarkers, and new therapeutic targets.
Collapse
Affiliation(s)
- Francesco Gentile
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology – San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Scarlino
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology – San Raffaele Scientific Institute, Milan, Italy
| | - Yuri Matteo Falzone
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology – San Raffaele Scientific Institute, Milan, Italy
- Department of Neurology, San Raffaele Scientific Institute, Milan, Italy
| | | | - Lucio Tremolizzo
- Neurology Unit, ALS Clinic, San Gerardo Hospital, University of Milano-Bicocca, Monza, Italy
| | - Angelo Quattrini
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology – San Raffaele Scientific Institute, Milan, Italy
| | - Nilo Riva
- Experimental Neuropathology Unit, Division of Neuroscience, Institute of Experimental Neurology – San Raffaele Scientific Institute, Milan, Italy
- Department of Neurology, San Raffaele Scientific Institute, Milan, Italy
| |
Collapse
|
18
|
Amin Lari A, Ghavanini AA, Bokaee HR. A review of electrophysiological studies of lower motor neuron involvement in amyotrophic lateral sclerosis. Neurol Sci 2019; 40:1125-1136. [PMID: 30877611 DOI: 10.1007/s10072-019-03832-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/07/2019] [Indexed: 02/08/2023]
Abstract
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease involving both the upper and lower motor neuron diseases. In this review, we studied and compared different articles regarding the electrodiagnostic criteria for diagnosis of lower motor neuron pathology in ALS. We reviewed the most recent articles and metaanalysis regarding various lower motor neuron electrodiagnostic methods for ALS and their sensitivities. We concluded that Awaji Shima criteria is by far the most sensitive criteria for diagnosis of ALS.
Collapse
Affiliation(s)
- Ali Amin Lari
- Canadian Neurologic Center, Mississauga, ON, Canada.
| | | | | |
Collapse
|
19
|
Delpont B, Beauvais K, Jacquin-Piques A, Alavoine V, Rault P, Blanc-Labarre C, Osseby GV, Hervieu-Bègue M, Giroud M, Béjot Y. Clinical features of pain in amyotrophic lateral sclerosis: A clinical challenge. Rev Neurol (Paris) 2018; 175:11-15. [PMID: 30131172 DOI: 10.1016/j.neurol.2017.11.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/09/2017] [Accepted: 11/20/2017] [Indexed: 12/12/2022]
Abstract
Pain in amyotrophic lateral sclerosis (ALS) is paradoxical in this disease of the upper and lower motor neurons. As such, it remains an underestimated and neglected clinical problem because it is poorly identified by physicians, its mechanisms are numerous and its treatments are generally not effective. Pain may be primary in the form of cramps, spasticity and neuropathy, or secondary as nociceptive pain, and may arise before the first motor symptoms. It may also lead to depression and, in all cases, affect patients' daily activities and quality of life. Given the high frequency of pain in ALS, the use of analgesic or sedative drugs is necessary and should reduce the course of the disease. Nevertheless, it is important to understand the pathophysiological mechanisms of pain in ALS, and to train physicians how to detect ALS pain early on and provide dedicated treatments. In France, the implementation of ALS centers is a positive response to the public-health problem resulting from this disorder.
Collapse
Affiliation(s)
- B Delpont
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France; Centre de Lutte contre la Douleur, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - K Beauvais
- Centre SLA, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - A Jacquin-Piques
- Centre SLA, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - V Alavoine
- Unité de Soins Palliatifs, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - P Rault
- Centre de Lutte contre la Douleur, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - C Blanc-Labarre
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - G-V Osseby
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France; Centre de Lutte contre la Douleur, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - M Hervieu-Bègue
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| | - M Giroud
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France; Centre de Lutte contre la Douleur, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France; Centre SLA, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France.
| | - Y Béjot
- Service de Neurologie, CHU de Dijon-Bourgogne, 14, rue Paul-Gaffarel, 21079 Dijon cedex, France
| |
Collapse
|
20
|
Tao QQ, Wei Q, Wu ZY. Sensory nerve disturbance in amyotrophic lateral sclerosis. Life Sci 2018; 203:242-245. [DOI: 10.1016/j.lfs.2018.04.052] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/16/2018] [Accepted: 04/26/2018] [Indexed: 12/11/2022]
|
21
|
Matamala JM, Howells J, Dharmadasa T, Huynh W, Park SB, Burke D, Kiernan MC. Excitability of sensory axons in amyotrophic lateral sclerosis. Clin Neurophysiol 2018; 129:1472-1478. [PMID: 29661595 DOI: 10.1016/j.clinph.2018.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 02/22/2018] [Accepted: 03/11/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the excitability of sensory axons in patients with amyotrophic lateral sclerosis (ALS). METHODS Comprehensive sensory nerve excitability studies were prospectively performed on 28 sporadic ALS patients, compared to age-matched controls. Sensory nerve action potentials were recorded from digit 2 following median nerve stimulation at the wrist. Disease severity was measured using motor unit number estimation (MUNE), the revised ALS Functional Rating Scale (ALSFRS-R) and the MRC scale. RESULTS There were no significant differences in standard and extended measures of nerve excitability between ALS patients and controls. These unchanged excitability measures included accommodation to long-lasting hyperpolarization and the threshold changes after two supramaximal stimuli during the recovery cycle. Excitability parameters did not correlate with MUNE, ALSFRS-R, APB MRC scale or disease duration. CONCLUSIONS This cross-sectional study has identified normal axonal membrane properties in myelinated sensory axons of ALS patients. Previously described sensory abnormalities could be the result of axonal fallout, possibly due to a ganglionopathy, or to involvement of central sensory pathways rostral to gracile and cuneate nuclei. SIGNIFICANCE These results demonstrate the absence of generalized dysfunction of the membrane properties of sensory axons in ALS in the face of substantial deficits in motor function.
Collapse
Affiliation(s)
| | - James Howells
- Brain and Mind Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - Thanuja Dharmadasa
- Brain and Mind Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - William Huynh
- Brain and Mind Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - Susanna B Park
- Brain and Mind Centre, University of Sydney, Sydney, NSW 2050, Australia
| | - David Burke
- Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, NSW 2050, Australia; Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia; Department of Neurology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| |
Collapse
|
22
|
Dharmadasa T, Matamala JM, Huynh W, Zoing MC, Kiernan MC. Motor neurone disease. HANDBOOK OF CLINICAL NEUROLOGY 2018; 159:345-357. [PMID: 30482326 DOI: 10.1016/b978-0-444-63916-5.00022-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Motor neurone disease (MND) patients exhibit poor gait, balance, and postural control, all of which significantly increases their risk of falling. Falls are frequent in the MND population, and are associated with an increased burden of disease. The complex interplay of both motor and extramotor manifestations in this disease contributes to the heterogeneous and multifactorial causes of such dysfunction. This review highlights the pathophysiologic influence of motor degeneration in gait disturbance, but also the additional influence on postural instability from other inputs such as cognitive impairment, autonomic dysregulation, cerebellar dysfunction, sensory impairment, and extrapyramidal involvement. In various combinations, these impairments are responsible for reduced gait speed and alteration in gait cycle, as well as structurally more variable and disorganized gait patterns. Based on these features, this chapter will also provide disease-specific interventions to assess, manage, and prevent falls in the MND cohort.
Collapse
Affiliation(s)
| | | | - William Huynh
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia; Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Margaret C Zoing
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia
| | - Matthew C Kiernan
- Brain and Mind Centre, University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
23
|
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] [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.
Collapse
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.
| |
Collapse
|
24
|
Kulkantrakorn K, Suksasunee D. Clinical, electrodiagnostic, and outcome correlation in ALS patients in Thailand. J Clin Neurosci 2017; 43:165-169. [DOI: 10.1016/j.jocn.2017.05.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/22/2017] [Indexed: 10/19/2022]
|
25
|
Lopes LCG, Galhardoni R, Silva V, Jorge FMH, Yeng LT, Callegaro D, Chadi G, Teixeira MJ, Ciampi de Andrade D. Beyond weakness: Characterization of pain, sensory profile and conditioned pain modulation in patients with motor neuron disease: A controlled study. Eur J Pain 2017; 22:72-83. [PMID: 28833988 DOI: 10.1002/ejp.1091] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Motor neuron diseases (MND) represent a group of disorders that evolve with inexorable muscle weakness and medical management is based on symptom control. However, deeper characterization of non-motor symptoms in these patients have been rarely reported. METHODS This cross-sectional study aimed to describe non-motor symptoms in MND and their impact on quality of life and functional status, with a focus on pain and sensory changes. Eighty patients (31 females, 55.7 ± 12.9 years old) with MND underwent a neurological examination, pain, mood, catastrophizing and psychophysics assessments [quantitative sensory testing (QST) and conditioned pain modulation (CPM)], and were compared to sex- and age-matched healthy controls (HC). RESULTS Chronic pain was present in 46% of patients (VAS =5.18 ± 2.0). Pain of musculoskeletal origin occurred in 40.5% and was mainly located in the head/neck (51%) and lower back (35%). Neuropathic pain was not present in this sample. Compared to HC, MND patients had a lower cold detection threshold (p < 0.002), and significantly lower CPM scores (4.9 ± 0.2% vs. 22.1 ± 0.2%, p = 0.012). QST/CPM results did not differ between MND patients with and without pain. Pain intensity was statistically correlated with anxiety, depression and catastrophism, and spasticity scores were inversely correlated with CPM (ρ = -0.30, p = 0.026). CONCLUSIONS Pain is frequently reported by patients with MNDs. Somatosensory and CPM changes exist in MNDs and may be related to the neurodegenerative nature of the disease. Further studies should investigate the most appropriate treatment strategies for these patients. SIGNIFICANCE We report a comprehensive evaluation of pain and sensory abnormalities in motor neuron disease (MND) patients. We assessed the different pain syndromes present in MND with validated tools, and described the QST and conditioned pain modulation profiles in a controlled design.
Collapse
Affiliation(s)
- L C G Lopes
- Pain Center, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo, Brazil.,Neurology Division, Department of Neurology, São Paulo State University (Unesp) Medical School, Botucatu, Brazil
| | - R Galhardoni
- Pain Center, Department of Neurology, University of São Paulo, Brazil.,Transcranial Magnetic Stimulation Laboratory, Psychiatry Institute, University of São Paulo, Brazil
| | - V Silva
- Transcranial Magnetic Stimulation Laboratory, Psychiatry Institute, University of São Paulo, Brazil
| | - F M H Jorge
- Neuroregeneration Center and ALS Brazil Project, Department of Neurology, University of São Paulo School of Medicine, Brazil
| | - L T Yeng
- Instituto de Ortopedia e Traumatologia, Division of Physical Medicine and Rehabilitation, University of São Paulo, Brazil
| | - D Callegaro
- Neuroimmunology Group, Department of Neurology, University of São Paulo, Brazil
| | - G Chadi
- Neuroregeneration Center and ALS Brazil Project, Department of Neurology, University of São Paulo School of Medicine, Brazil
| | - M J Teixeira
- Pain Center, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo, Brazil.,Pain Center, Department of Neurology, University of São Paulo, Brazil.,Transcranial Magnetic Stimulation Laboratory, Psychiatry Institute, University of São Paulo, Brazil
| | - D Ciampi de Andrade
- Pain Center, Instituto do Câncer do Estado de São Paulo Octavio Frias de Oliveira, São Paulo, Brazil.,Pain Center, Department of Neurology, University of São Paulo, Brazil.,Transcranial Magnetic Stimulation Laboratory, Psychiatry Institute, University of São Paulo, Brazil
| |
Collapse
|
26
|
Kural MA, Karlsson P, Pugdahl K, Isak B, Fuglsang-Frederiksen A, Tankisi H. Diagnostic utility of distal nerve conduction studies and sural near-nerve needle recording in polyneuropathy. Clin Neurophysiol 2017; 128:1590-1595. [PMID: 28710923 DOI: 10.1016/j.clinph.2017.06.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/16/2017] [Accepted: 06/09/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The electrodiagnosis of polyneuropathy (PNP) may benefit from examination using near-nerve needle technique (NNT) and from inclusion of distal nerves. This study compared the diagnostic utility of distal nerve conduction studies (NCS) and NNT recording. METHODS Bilateral NNT and surface recording of the sural nerve and surface recording of the dorsal sural and medial plantar nerves were prospectively done in 91 patients with clinically suspected PNP. Distal NCS were additionally done in 37 healthy controls. Diagnostic reference standard was the final clinical diagnosis retrieved from the patients medical records after 1-4years. RESULTS The clinical follow-up diagnosis confirmed PNP in 68 patients. Equally high sensitivities of the dorsal sural (72%), medial plantar (75%), and sural nerve with NNT recording (77%) were seen, while the sensitivity of conventional surface recording of the sural nerve was lower (60%). Sural NCS with both NNT and surface recording and dorsal sural NCS showed high specificities (85-95%) and positive predictive values (94-98%), while a lower specificity was seen for the medial plantar nerve (68%). CONCLUSION NCS of distal nerves, especially the dorsal sural nerve, have high diagnostic power equalling sural NNT recording. SIGNIFICANCE The electrodiagnostic evaluation of patients with suspected PNP benefits from NCS of distal nerves.
Collapse
Affiliation(s)
- Mustafa Aykut Kural
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Páll Karlsson
- Danish Pain Research Centre, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kirsten Pugdahl
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Baris Isak
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark.
| |
Collapse
|
27
|
Quantitative sensory testing and structural assessment of sensory nerve fibres in amyotrophic lateral sclerosis. J Neurol Sci 2017; 373:329-334. [DOI: 10.1016/j.jns.2017.01.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 12/12/2016] [Accepted: 01/03/2017] [Indexed: 11/22/2022]
|
28
|
Pain in amyotrophic lateral sclerosis. Lancet Neurol 2017; 16:144-157. [DOI: 10.1016/s1474-4422(16)30358-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 10/31/2016] [Accepted: 11/21/2016] [Indexed: 12/12/2022]
|
29
|
McCombe PA, Wray NR, Henderson RD. Extra-motor abnormalities in amyotrophic lateral sclerosis: another layer of heterogeneity. Expert Rev Neurother 2017; 17:561-577. [PMID: 27983884 DOI: 10.1080/14737175.2017.1273772] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease defined by the presence of muscle weakness. The motor features of disease are heterogeneous in site of onset and progression. There are also extra-motor features in some patients. The genetic basis for extra-motor features is uncertain. The heterogeneity of ALS is an issue for clinical trials. Areas covered: This paper reviews the range and prevalence of extra-motor features associated with ALS, and highlights the current information about genetic associations with extra-motor features. Expert commentary: There are extra-motor features of ALS, but these are not found in all patients. The most common is cognitive abnormality. More data is required to ascertain whether extra-motor features arise with progression of disease. Extra-motor features are reported in patients with a range of causative genetic mutations, but are not found in all patients with these mutations. Further studies are required of the heterogeneity of ALS, and genotype/phenotype correlations are required, taking note of extra-motor features.
Collapse
Affiliation(s)
- P A McCombe
- a The University of Queensland Centre for Clinical Research and Department of Neurology, Royal Brisbane and Women's Hospital , Brisbane , Australia
| | - N R Wray
- b The University of Queensland Institute for Molecular Bioscience , Brisbane , Australia
| | - R D Henderson
- a The University of Queensland Centre for Clinical Research and Department of Neurology, Royal Brisbane and Women's Hospital , Brisbane , Australia
| |
Collapse
|
30
|
Isak B, Tankisi H, Johnsen B, Pugdahl K, Finnerup NB, Fuglsang-Frederiksen A. Laser and somatosensory evoked potentials in amyotrophic lateral sclerosis. Clin Neurophysiol 2016; 127:3322-8. [DOI: 10.1016/j.clinph.2016.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 07/11/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
|