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Libri I, Cantoni V, Benussi A, Rivolta J, Ferrari C, Fancellu R, Synofzik M, Alberici A, Padovani A, Borroni B. Comparing Cerebellar tDCS and Cerebellar tACS in Neurodegenerative Ataxias Using Wearable Sensors: A Randomized, Double-Blind, Sham-Controlled, Triple-Crossover Trial. CEREBELLUM (LONDON, ENGLAND) 2024; 23:570-578. [PMID: 37349632 PMCID: PMC10951038 DOI: 10.1007/s12311-023-01578-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/09/2023] [Indexed: 06/24/2023]
Abstract
Cerebellar transcranial direct current stimulation (tDCS) represents a promising therapeutic approach for both motor and cognitive symptoms in neurodegenerative ataxias. Recently, transcranial alternating current stimulation (tACS) was also demonstrated to modulate cerebellar excitability by neuronal entrainment. To compare the effectiveness of cerebellar tDCS vs. cerebellar tACS in patients with neurodegenerative ataxia, we performed a double-blind, randomized, sham controlled, triple cross-over trial with cerebellar tDCS, cerebellar tACS or sham stimulation in twenty-six participants with neurodegenerative ataxia. Before entering the study, each participant underwent motor assessment with wearable sensors considering gait cadence (steps/minute), turn velocity (degrees/second) and turn duration (seconds), and a clinical evaluation with the scale for the Assessment and Rating of Ataxia (SARA) and the International Cooperative Ataxia Rating Scale (ICARS). After each intervention, participants underwent the same clinical assessment along with cerebellar inhibition (CBI) measurement, a marker of cerebellar activity. The gait cadence, turn velocity, SARA, and ICARS significantly improved after both tDCS and tACS, compared to sham stimulation (all p<0.010). Comparable effects were observed for CBI (p<0.001). Overall, tDCS significantly outperformed tACS on clinical scales and CBI (p<0.01). A significant correlation between changes of wearable sensors parameters from baseline and changes of clinical scales and CBI scores was detected. Cerebellar tDCS and cerebellar tACS are effective in ameliorating symptoms of neurodegenerative ataxias, with the former being more beneficial than the latter. Wearable sensors may serve as rater-unbiased outcome measures in future clinical trials. ClinicalTrial.gov Identifier: NCT05621200.
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Affiliation(s)
- Ilenia Libri
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Valentina Cantoni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alberto Benussi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Jasmine Rivolta
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Camilla Ferrari
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Roberto Fancellu
- UO Neurologia, IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy
| | - Matthis Synofzik
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research and Centre of Neurology, Tübingen, Germany
- German Research Center for Neurodegenerative Diseases (DZNE), Tübingen, Germany
| | - Antonella Alberici
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Barbara Borroni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
- Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy.
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Jiménez-García AM, Bonnel G, Álvarez-Mota A, Arias N. Current perspectives on neuromodulation in ALS patients: A systematic review and meta-analysis. PLoS One 2024; 19:e0300671. [PMID: 38551974 PMCID: PMC10980254 DOI: 10.1371/journal.pone.0300671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 03/01/2024] [Indexed: 04/01/2024] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a progressive neurodegenerative disease that affects motor neurons, resulting in muscle weakness, paralysis, and eventually patient mortality. In recent years, neuromodulation techniques have emerged as promising potential therapeutic approaches to slow disease progression and improve the quality of life of ALS patients. A systematic review was conducted until August 8, 2023, to evaluate the neuromodulation methods used and their potential in the treatment of ALS. The search strategy was applied in the Cochrane Central database, incorporating results from other databases such as PubMed, Embase, CTgov, CINAHL, and ICTRP. Following the exclusion of papers that did not fulfil the inclusion criteria, a total of 2090 records were found, leaving a total of 10 studies. R software was used to conduct meta-analyses based on the effect sizes between the experimental and control groups. This revealed differences in muscle stretch measures with manual muscle testing (p = 0.012) and resting motor threshold (p = 0.0457), but not with voluntary isometric contraction (p = 0.1883). The functionality of ALS was also different (p = 0.007), but not the quality of life. Although intracortical facilitation was not seen in motor cortex 1 (M1) (p = 0.1338), short-interval intracortical inhibition of M1 was significant (p = 0.0001). BDNF showed no differences that were statistically significant (p = 0.2297). Neuromodulation-based treatments are proposed as a promising therapeutic approach for ALS that can produce effects on muscle function, spasticity, and intracortical connections through electrical, magnetic, and photonic stimulation. Photobiomodulation stands out as an innovative approach that uses specific wavelengths to influence mitochondria, with the aim of improving mitochondrial function and reducing excitotoxicity. The lack of reliable placebo controls and the variation in stimulation frequency are some of the drawbacks of neuromodulation.
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Affiliation(s)
- Ana M. Jiménez-García
- BRABE Group, Department of Psychology, Faculty of Life and Natural Sciences, University of Nebrija, Madrid, Spain
| | - Gaspard Bonnel
- BRABE Group, Department of Psychology, Faculty of Life and Natural Sciences, University of Nebrija, Madrid, Spain
| | - Alicia Álvarez-Mota
- BRABE Group, Department of Psychology, Faculty of Life and Natural Sciences, University of Nebrija, Madrid, Spain
| | - Natalia Arias
- BRABE Group, Department of Psychology, Faculty of Life and Natural Sciences, University of Nebrija, Madrid, Spain
- Health Research Institute of the Principality of Asturias (Instituto de Investigación Universitaria del Principado de Asturias), Oviedo, Spain
- INEUROPA, Instituto de Neurociencias del Principado de Asturias, Plaza Feijoo, Oviedo, Spain
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Di Lazzaro V, Ranieri F, Bączyk M, de Carvalho M, Dileone M, Dubbioso R, Fernandes S, Kozak G, Motolese F, Ziemann U. Novel approaches to motoneuron disease/ALS treatment using non-invasive brain and spinal stimulation: IFCN handbook chapter. Clin Neurophysiol 2024; 158:114-136. [PMID: 38218077 DOI: 10.1016/j.clinph.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/17/2023] [Indexed: 01/15/2024]
Abstract
Non-invasive brain stimulation techniques have been exploited in motor neuron disease (MND) with multifold objectives: to support the diagnosis, to get insights in the pathophysiology of these disorders and, more recently, to slow down disease progression. In this review, we consider how neuromodulation can now be employed to treat MND, with specific attention to amyotrophic lateral sclerosis (ALS), the most common form with upper motoneuron (UMN) involvement, taking into account electrophysiological abnormalities revealed by human and animal studies that can be targeted by neuromodulation techniques. This review article encompasses repetitive transcranial magnetic stimulation methods (including low-frequency, high-frequency, and pattern stimulation paradigms), transcranial direct current stimulation as well as experimental findings with the newer approach of trans-spinal direct current stimulation. We also survey and discuss the trials that have been performed, and future perspectives.
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Affiliation(s)
- Vincenzo Di Lazzaro
- Department of Medicine and Surgery, Unit of Neurology, Neurophysiology, Neurobiology and Psychiatry, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128 Roma, Italy; Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy.
| | - Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, P.Le L.A. Scuro 10, 37134 Verona, Italy
| | - Marcin Bączyk
- Department of Neurobiology, Poznań University of Physical Education, Królowej Jadwigi Street 27/39, 61-871 Poznań, Poland
| | - Mamede de Carvalho
- Institute of Physiology, Institute of Molecular Medicine-JLA, Egas Moniz Study Centre, Faculty of Medicine, University of Lisbon, Lisbon 1649-028, Portugal; Department of Neurosciences and Mental Health, CHULN, Lisbon, Portugal
| | - Michele Dileone
- Faculty of Health Sciences, UCLM Talavera de la Reina, Toledo, Spain; Neurology Department, Hospital Nuestra Señora del Prado, Talavera de la Reina, Toledo, Spain
| | - Raffaele Dubbioso
- Neurophysiology Unit, Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples "Federico II", Napoli, Italy
| | - Sofia Fernandes
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, Campo Grande, 1749-016-Lisboa, Portugal
| | - Gabor Kozak
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Francesco Motolese
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128 Roma, Italy
| | - Ulf Ziemann
- Department of Neurology and Stroke, University of Tübingen, Tübingen, Germany; Hertie-Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany.
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Benussi A, Cantoni V, Grassi M, Libri I, Cotelli MS, Tarantino B, Datta A, Thomas C, Huber N, Kärkkäinen S, Herukka SK, Haapasalo A, Filosto M, Padovani A, Borroni B. Cortico-spinal tDCS in amyotrophic lateral sclerosis: A randomized, double-blind, sham-controlled trial followed by an open-label phase. Brain Stimul 2023; 16:1666-1676. [PMID: 37977335 DOI: 10.1016/j.brs.2023.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a progressive disease for which no curative treatment is currently available. OBJECTIVE This study aimed to investigate whether cortico-spinal transcranial direct current stimulation (tDCS) could mitigate symptoms in ALS patients via a randomized, double-blind, sham-controlled trial, followed by an open-label phase. METHODS Thirty-one participants were randomized into two groups for the initial controlled phase. At baseline (T0), Group 1 received placebo stimulation (sham tDCS), while Group 2 received cortico-spinal stimulation (real tDCS) for five days/week for two weeks (T1), with an 8-week (T2) follow-up (randomized, double-blind, sham-controlled phase). At the 24-week follow-up (T3), all participants (Groups 1 and 2) received a second treatment of anodal bilateral motor cortex and cathodal spinal stimulation (real tDCS) for five days/week for two weeks (T4). Follow-up evaluations were performed at 32-weeks (T5) and 48-weeks (T6) (open-label phase). At each time point, clinical assessment, blood sampling, and intracortical connectivity measures using transcranial magnetic stimulation (TMS) were evaluated. Additionally, we evaluated survival rates. RESULTS Compared to sham stimulation, cortico-spinal tDCS significantly improved global strength, caregiver burden, and quality of life scores, which correlated with the restoration of intracortical connectivity measures. Serum neurofilament light levels decreased among patients who underwent real tDCS but not in those receiving sham tDCS. The number of completed 2-week tDCS treatments significantly influenced patient survival. CONCLUSIONS Cortico-spinal tDCS may represent a promising therapeutic and rehabilitative approach for patients with ALS. Further larger-scale studies are necessary to evaluate whether tDCS could potentially impact patient survival. CLINICAL TRIAL REGISTRATION NCT04293484.
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Affiliation(s)
- Alberto Benussi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Valentina Cantoni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Mario Grassi
- Department of Brain and Behavioural Sciences, Medical and Genomic Statistics Unit, University of Pavia, Pavia, Italy
| | - Ilenia Libri
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | | | - Barbara Tarantino
- Department of Brain and Behavioural Sciences, Medical and Genomic Statistics Unit, University of Pavia, Pavia, Italy
| | - Abhishek Datta
- Research & Development, Soterix Medical, Inc., New York, USA
| | - Chris Thomas
- Research & Development, Soterix Medical, Inc., New York, USA
| | - Nadine Huber
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Sari Kärkkäinen
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland
| | - Sanna-Kaisa Herukka
- Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio, Finland; Department of Neurology, Kuopio University Hospital, Kuopio, Finland
| | - Annakaisa Haapasalo
- A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland
| | - Massimiliano Filosto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; NeMo-Brescia Clinical Center for Neuromuscular Diseases, Gussago, Brescia, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Barbara Borroni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili di Brescia, Brescia, Italy.
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Ahmed N, Baker MR, Bashford J. The landscape of neurophysiological outcome measures in ALS interventional trials: A systematic review. Clin Neurophysiol 2022; 137:132-141. [PMID: 35313253 PMCID: PMC10166714 DOI: 10.1016/j.clinph.2022.02.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/11/2022] [Accepted: 02/18/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE We collated all interventional clinical trials in amyotrophic lateral sclerosis (ALS), which utilised at least one neurophysiological technique as a primary or secondary outcome measure. By identifying the strengths and limitations of these studies, we aim to guide study design in future trials. METHODS We conducted and reported this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eight databases were searched from inception. In total, 703 studies were retrieved for screening and eligibility assessment. RESULTS Dating back to 1986, 32 eligible interventional clinical trials were identified, recruiting a median of 30 patients per completed trial. The most widely employed neurophysiological techniques were electromyography, motor unit number estimation (including motor unit number index), neurophysiological index and transcranial magnetic stimulation (including resting motor threshold and short-interval intracortical inhibition). Almost 40% of trials reported a positive outcome with respect to at least one neurophysiological measure. The interventions targeted either ion channels, immune mechanisms or neuronal metabolic pathways. CONCLUSIONS Neurophysiology offers many promising biomarkers that can be utilised as outcome measures in interventional clinical trials in ALS. When selecting the most appropriate technique, key considerations include methodological standardisation, target engagement and logistical burden. SIGNIFICANCE Future trial design in ALS would benefit from a standardised, updated and easily accessible repository of neurophysiological outcome measures.
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Affiliation(s)
- N Ahmed
- GKT School of Medical Education, Faculty of Life Sciences and Medicine, King's College London, UK
| | - M R Baker
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle Upon Tyne, UK
| | - J Bashford
- UK Dementia Research Institute, Department of Basic and Clinical Neuroscience, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
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Shibuya K, Otani R, Suzuki YI, Kuwabara S, Kiernan MC. Neuronal Hyperexcitability and Free Radical Toxicity in Amyotrophic Lateral Sclerosis: Established and Future Targets. Pharmaceuticals (Basel) 2022; 15:ph15040433. [PMID: 35455429 PMCID: PMC9025031 DOI: 10.3390/ph15040433] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/24/2022] [Accepted: 03/29/2022] [Indexed: 02/04/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a devastating disease with evidence of degeneration involving upper and lower motor neuron compartments of the nervous system. Presently, two drugs, riluzole and edaravone, have been established as being useful in slowing disease progression in ALS. Riluzole possesses anti-glutamatergic properties, while edaravone eliminates free radicals (FRs). Glutamate is the excitatory neurotransmitter in the brain and spinal cord and binds to several inotropic receptors. Excessive activation of these receptors generates FRs, inducing neurodegeneration via damage to intracellular organelles and upregulation of proinflammatory mediators. FRs bind to intracellular structures, leading to cellular impairment that contributes to neurodegeneration. As such, excitotoxicity and FR toxicities have been considered as key pathophysiological mechanisms that contribute to the cascade of degeneration that envelopes neurons in ALS. Recent advanced technologies, including neurophysiological, imaging, pathological and biochemical techniques, have concurrently identified evidence of increased excitability in ALS. This review focuses on the relationship between FRs and excitotoxicity in motor neuronal degeneration in ALS and introduces concepts linked to increased excitability across both compartments of the human nervous system. Within this cellular framework, future strategies to promote therapeutic development in ALS, from the perspective of neuronal excitability and function, will be critically appraised.
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Affiliation(s)
- Kazumoto Shibuya
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan; (K.S.); (R.O.); (Y.-i.S.); (S.K.)
| | - Ryo Otani
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan; (K.S.); (R.O.); (Y.-i.S.); (S.K.)
| | - Yo-ichi Suzuki
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan; (K.S.); (R.O.); (Y.-i.S.); (S.K.)
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan; (K.S.); (R.O.); (Y.-i.S.); (S.K.)
| | - Matthew C. Kiernan
- Brain and Mind Centre, Department of Neurology, University of Sydney, Royal Prince Alfred Hospital, Sydney 2050, Australia
- Correspondence:
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Brain Connectivity and Network Analysis in Amyotrophic Lateral Sclerosis. Neurol Res Int 2022; 2022:1838682. [PMID: 35178253 PMCID: PMC8844436 DOI: 10.1155/2022/1838682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/13/2022] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease with no effective treatment or cure. ALS is characterized by the death of lower motor neurons (LMNs) in the spinal cord and upper motor neurons (UMNs) in the brain and their networks. Since the lower motor neurons are under the control of UMN and the networks, cortical degeneration may play a vital role in the pathophysiology of ALS. These changes that are not apparent on routine imaging with CT scans or MRI brain can be identified using modalities such as diffusion tensor imaging, functional MRI, arterial spin labelling (ASL), electroencephalogram (EEG), magnetoencephalogram (MEG), functional near-infrared spectroscopy (fNIRS), and positron emission tomography (PET) scan. They can help us generate a representation of brain networks and connectivity that can be visualized and parsed out to characterize and quantify the underlying pathophysiology in ALS. In addition, network analysis using graph measures provides a novel way of understanding the complex network changes occurring in the brain. These have the potential to become biomarker for the diagnosis and treatment of ALS. This article is a systematic review and overview of the various connectivity and network-based studies in ALS.
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Benussi A, Cantoni V, Manes M, Libri I, Dell'Era V, Datta A, Thomas C, Ferrari C, Di Fonzo A, Fancellu R, Grassi M, Brusco A, Alberici A, Borroni B. Motor and cognitive outcomes of cerebello-spinal stimulation in neurodegenerative ataxia. Brain 2021; 144:2310-2321. [PMID: 33950222 DOI: 10.1093/brain/awab157] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/20/2021] [Accepted: 04/01/2021] [Indexed: 11/12/2022] Open
Abstract
Cerebellar ataxias represent a heterogeneous group of disabling disorders characterized by motor and cognitive disturbances, for which no effective treatment is currently available. In this randomized, double-blind, sham-controlled trial, followed by an open-label phase, we investigated whether treatment with cerebello-spinal transcranial direct current stimulation (tDCS) could improve both motor and cognitive symptoms in patients with neurodegenerative ataxia at short and long-term. Sixty-one patients were randomized in two groups for the first controlled phase. At baseline (T0), Group 1 received placebo stimulation (sham tDCS) while Group 2 received anodal cerebellar tDCS and cathodal spinal tDCS (real tDCS) for 5 days/week for two weeks (T1), with a 12-week (T2) follow-up (randomized, double-blind, sham controlled phase). At the 12-week follow-up (T2), all patients (Group 1 and Group 2) received a second treatment of anodal cerebellar tDCS and cathodal spinal tDCS (real tDCS) for 5 days/week for two weeks, with a 14-week (T3), 24-week (T4), 36-week (T5) and 52-week follow-up (T6) (open-label phase). At each time point, a clinical, neuropsychological and neurophysiological evaluation was performed. Cerebellar-motor cortex connectivity was evaluated using transcranial magnetic stimulation (TMS). We observed a significant improvement in all motor scores (scale for the assessment and rating of ataxia, international cooperative ataxia rating scale), in cognition (evaluated with the cerebellar cognitive affective syndrome scale), in quality-of-life scores, in motor cortex excitability and in cerebellar inhibition after real tDCS compared to sham stimulation and compared to baseline (T0), both at short and long-term. We observed an addon-effect after two repeated treatments with real tDCS compared to a single treatment with real tDCS. The improvement at motor and cognitive scores correlated with the restoration of cerebellar inhibition evaluated with TMS. Cerebello-spinal tDCS represents a promising therapeutic approach for both motor and cognitive symptoms in patients with neurodegenerative ataxia, a still orphan disorder of any pharmacological intervention.
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Affiliation(s)
- Alberto Benussi
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
| | - Valentina Cantoni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Marta Manes
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Neurology Unit, Aulss2 Marca Trevigiana, Treviso, Italy
| | - Ilenia Libri
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Valentina Dell'Era
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Department of Neurology, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Abhishek Datta
- Research & Development, Soterix Medical, Inc., New York, USA
| | - Chris Thomas
- Research & Development, Soterix Medical, Inc., New York, USA
| | - Camilla Ferrari
- Department of Neuroscience, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Italy
| | - Alessio Di Fonzo
- Dino Ferrari Center, Neuroscience Section, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Neurology Unit, Milan, Italy
| | - Roberto Fancellu
- UO Neurologia, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Mario Grassi
- Department of Brain and Behavioural Sciences, Medical and Genomic Statistics Unit, University of Pavia, Pavia, Italy
| | - Alfredo Brusco
- Department of Medical Sciences, University of Torino, Torino, Italy.,Medical Genetics Unit, Città della Salute e della Scienza di Torino, Torino, Italy
| | - Antonella Alberici
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Barbara Borroni
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,Neurology Unit, Department of Neurological and Vision Sciences, ASST Spedali Civili, Brescia, Italy
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Ranieri F, Mariotto S, Dubbioso R, Di Lazzaro V. Brain Stimulation as a Therapeutic Tool in Amyotrophic Lateral Sclerosis: Current Status and Interaction With Mechanisms of Altered Cortical Excitability. Front Neurol 2021; 11:605335. [PMID: 33613416 PMCID: PMC7892772 DOI: 10.3389/fneur.2020.605335] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
In the last 20 years, several modalities of neuromodulation, mainly based on non-invasive brain stimulation (NIBS) techniques, have been tested as a non-pharmacological therapeutic approach to slow disease progression in amyotrophic lateral sclerosis (ALS). In both sporadic and familial ALS cases, neurophysiological studies point to motor cortical hyperexcitability as a possible priming factor in neurodegeneration, likely related to dysfunction of both excitatory and inhibitory mechanisms. A trans-synaptic anterograde mechanism of excitotoxicity is thus postulated, causing upper and lower motor neuron degeneration. Specifically, motor neuron hyperexcitability and hyperactivity are attributed to intrinsic cell abnormalities related to altered ion homeostasis and to impaired glutamate and gamma aminobutyric acid gamma-aminobutyric acid (GABA) signaling. Several neuropathological mechanisms support excitatory and synaptic dysfunction in ALS; additionally, hyperexcitability seems to drive DNA-binding protein 43-kDA (TDP-43) pathology, through the upregulation of unusual isoforms directly contributing to ASL pathophysiology. Corticospinal excitability can be suppressed or enhanced using NIBS techniques, namely, repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), as well as invasive brain and spinal stimulation. Experimental evidence supports the hypothesis that the after-effects of NIBS are mediated by long-term potentiation (LTP)-/long-term depression (LTD)-like mechanisms of modulation of synaptic activity, with different biological and physiological mechanisms underlying the effects of tDCS and rTMS and, possibly, of different rTMS protocols. This potential has led to several small trials testing different stimulation interventions to antagonize excitotoxicity in ALS. Overall, these studies suggest a possible efficacy of neuromodulation in determining a slight reduction of disease progression, related to the type, duration, and frequency of treatment, but current evidence remains preliminary. Main limitations are the small number and heterogeneity of recruited patients, the limited "dosage" of brain stimulation that can be delivered in the hospital setting, the lack of a sufficient knowledge on the excitatory and inhibitory mechanisms targeted by specific stimulation interventions, and the persistent uncertainty on the key pathophysiological processes leading to motor neuron loss. The present review article provides an update on the state of the art of neuromodulation in ALS and a critical appraisal of the rationale for the application/optimization of brain stimulation interventions, in the light of their interaction with ALS pathophysiological mechanisms.
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Affiliation(s)
- Federico Ranieri
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Mariotto
- Neurology Unit, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Raffaele Dubbioso
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, University of Naples “Federico II”, Naples, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Campus Bio-Medico University, Rome, Italy
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10
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Di Lazzaro V, Musumeci G, Boscarino M, De Liso A, Motolese F, Di Pino G, Capone F, Ranieri F. Transcranial static magnetic field stimulation can modify disease progression in amyotrophic lateral sclerosis. Brain Stimul 2020; 14:51-54. [PMID: 33186779 DOI: 10.1016/j.brs.2020.11.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/20/2020] [Accepted: 11/04/2020] [Indexed: 12/13/2022] Open
Affiliation(s)
- Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy.
| | - Gabriella Musumeci
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Marilisa Boscarino
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Alfredo De Liso
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Francesco Motolese
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Giovanni Di Pino
- Research Unit of Neurophysiology and Neuroengineering of Human-Technology Interaction (NeXTlab), Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Fioravante Capone
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, Università Campus Bio-Medico di Roma, Via Álvaro Del Portillo 21, 00128, Rome, Italy
| | - Federico Ranieri
- Unit of Neurology, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, P.le L.A. Scuro 10, 37134, Verona, Italy
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11
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Liscic RM, Alberici A, Cairns NJ, Romano M, Buratti E. From basic research to the clinic: innovative therapies for ALS and FTD in the pipeline. Mol Neurodegener 2020; 15:31. [PMID: 32487123 PMCID: PMC7268618 DOI: 10.1186/s13024-020-00373-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 03/27/2020] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis (ALS) and Frontotemporal Degeneration (FTD) are neurodegenerative disorders, related by deterioration of motor and cognitive functions and short survival. Aside from cases with an inherited pathogenic mutation, the causes of the disorders are still largely unknown and no effective treatment currently exists. It has been shown that FTD may coexist with ALS and this overlap occurs at clinical, genetic, and molecular levels. In this work, we review the main pathological aspects of these complex diseases and discuss how the integration of the novel pathogenic molecular insights and the analysis of molecular interaction networks among all the genetic players represents a critical step to shed light on discovering novel therapeutic strategies and possibly tailoring personalized medicine approaches to specific ALS and FTD patients.
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Affiliation(s)
- Rajka Maria Liscic
- Department of Neurology, Johannes Kepler University, Linz, Austria
- School of Medicine, University of Osijek, Osijek, Croatia
| | - Antonella Alberici
- Neurology Unit, Department of Neurological Sciences and Vision, ASST-Spedali Civili-University of Brescia, Brescia, Italy
| | - Nigel John Cairns
- College of Medicine and Health and Living Systems Institute, University of Exeter, Exeter, UK
| | - Maurizio Romano
- Department of Life Sciences, Via Valerio 28, University of Trieste, 34127, Trieste, Italy
| | - Emanuele Buratti
- International Centre for Genetic Engineering and Biotechnology (ICGEB), Padriciano 99, 34149, Trieste, Italy.
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