Stiff man syndrome

The Effectiveness of Combining Botulinum Toxin Type A and Therapeutic Exercise in Treating Spasticity in a Patient with Complicated Stiff-Person Syndrome: A Case Report

Stiff-person syndrome is rare and disabling autoimmune condition that most frequently affects women, with no real predisposition by race. Diagnosis is often arduous, which is why patients concomitantly suffer from anxiety and depression. To date, drug therapy is based on the use of benzodiazepines, barbiturates, and baclofen. Refractory cases are treated with intravenous immunoglobulin, plasmapheresis, B lymphocyte depletion with rituximab, and even the implantation of intrathecal baclofen devices. Botulinum toxin injection is frequently used, even if it still has an unclear role in the literature. Our case report aims to demonstrate the efficacy of a combined treatment of botulinum toxin and therapeutic exercise in a 65-year-old patient with biceps brachii muscle hypertonia and diffuse spasms of the axial musculature, using rating scales such as the Numeric Rating Scale (NRS) and Modified Ashworth Scale (MAS), joint range of motion (ROM) measurement, and muscle dynamic stiffness mensuration, which is performed by using the MyotonPro®. All the assessments were conducted at the first evaluation (T0), soon after the combined treatment with botulin toxin and therapeutic exercise (T1), three months (T2), six months (T3), and eight months after the botulinum toxin injection (T4). The patient demonstrated benefits for more than 6 months with no side effects. The combined therapy of botulinum toxin and therapeutic exercise had an excellent result in our patient.

The effect of clinical pilates-based physiotherapy program for a Stiff Person Syndrome patient: a case report

The aim of the present report is to show the effects of a clinical pilates-based physiotherapy training program on physical functioning, including balance ability, flexibility, muscle strength, and pain severity in a case with Stiff Person Syndrome (SPS). A 43-year-old female with a 3-year history of SPS participated in the study. Clinical pilates training exercises were performed two times per week during 8 weeks. Static balance was evaluated with One Leg Stance Test and Tandem Stance Test, dynamic balance with Functional Reach Test and lower extremity strength and endurance measured by 30-s Chair Stand Test. Berg Balance Scale was used to assess balance and fall risk, and Timed Up and Go Test was used to assess functional mobility. Pain evaluation was done by Pain Quality Assessment Scale. Flexibility was measured with tape measure, range of motion with goniometer and muscle strength with manual muscle test. Among the balance and functional mobility tests, progress has been observed in all tests, except for 30-s Chair Stand test. Improvements have been observed in patient's range of motion, flexibility, strength, pain and balance parameters. Clinical pilates-based physiotherapy program had positive effects on many physical and functional parameters of the patient and can be used as a safe exercise method in physiotherapy rehabilitation of SPS.

Anti-glutamic acid decarboxylase antibody (GAD) syndromes may have more aggressive disease course in African Americans and early onset of presentation compare to Caucasians group

Anti-Glutamic acid decarboxylase antibodies (GAD) are increasingly diagnosed in the clinic and this antibody related syndromes can manifest commonly as autoimmune encephalitis, Stiff person syndrome and cerebellar ataxia. However, it is unclear if the race has role in age of incidence, presentation and severity of symptoms of anti-GAD associated conditions. In our cohort of 40 patients who were anti-GAD positive, we observed that the age at which the anti-GAD titers turned out to be positive was significantly lower in African Americans (AA) compared to Caucasians (Cau) irrespective of the type of conditions. However, the age at symptoms onset didn't differ significantly different between these groups. Furthermore, AA anti-GAD positive patients had seizures as their initial presentation that was significantly higher in incidence compared to Cau indicating that AA have more aggressive form of autoimmune phenomenon for reasons unknown. Future studies to explore the variations in autoimmune process and their phenotypes may aid in understanding anti-GAD syndromes differently between these racial groups.

SPS: Understanding the complexity

INTRODUCTION

Stiff-person syndrome (SPS), first described in 1956 by Moersch and Woltman, is a progressive autoimmune disorder with core features of chronic fluctuating progressive truncal and limb rigidity and painful muscle spasms leading to gait difficulties, falls and an appearance that resembles tin soldiers. The syndrome is a rare, highly disabling disorder of the central nervous and frequently results in significant disability. Understanding of the etiology, clinical spectrum, diagnostic workup and therapeutic modalities for this painful and disabling disorder has vastly evolved over the past few years with more confidence in classifying and treating the patients. The purpose of this review is to increase the awareness, early detection, and treatment of this disabling disease.

METHOD

PubMed was searched, all date inclusive, using the following phrases: stiff person syndrome,anti-Glutamic acid decarboxylase (Anti-GAD) antibody syndrome, Progressive encephalomyelitis with rigidity and myoclonus (PERM), and Paraneoplastic Stiff Person syndrome. No filters or restrictions were used. A total of 888 articles were identified.

RESULTS

The results were narrowed to 190 citations after excluding non-English and duplicate reports. Clinical presentation, laboratory testing, treatment, and prognosis were categorized and summarized.

DISCUSSION

In this article we will discuss the epidemiology, presentation and classification. Explain the pathophysiology of SPS and the autoimmune mechanisms involved. Discuss the diagnostic approach and treatments available, as well as, the prognosis and outcome.

Paraneoplastic movement disorders

Paraneoplastic movement disorders are rare, autoimmune-mediated, nonmetastatic complications of malignant neoplasms. Common paraneoplastic movement disorders include paraneoplastic chorea, dystonia, cerebellar degeneration, different types of encephalitis, opsoclonus-myoclonus syndrome, stiff person syndrome, and neuromyotonia. Syndromes usually develop before tumor diagnosis, have subacute onset, and are associated with serum or cerebrospinal fluid antibodies. Two types of antibodies can be distinguished: antibodies against nuclear and cytoplasmic neuronal antigens (anti-Hu, anti-Ri, anti-Yo, anti-Ma, anti-CV2/CRMP5, anti-Gephrin, and anti-GABATRAP) and antibodies recently identified against cell surface and synaptic proteins (anti-NMDAR, anti-LGI1, and anti-Caspr2). These two types differ from each other in a few important aspects. Antibodies against cell surface and synaptic protein disrupt cell-surface antigens. Clinical symptoms are related to the disruption of antigens and potentially can be reversed by immunotherapy. The association between these antibodies and malignancy is much less consistent. On the other hand, antibodies against nuclear and cytoplasmic neuronal antigens seem to be not pathogenic; however, they most likely indicate a T-cell-mediated immune response against neurons. Due to T-cell-mediated neuronal loss, response to immunotherapy is generally disappointing. Early recognition of all these diseases is crucial because it may lead to the disclosure of occult cancer. This review is focused on paraneoplastic movement disorders with emphasis on clinical presentations, investigational findings, and therapeutic results.

Anti-glutamic acid decarboxylase antibody positive neurological syndromes

A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were calledhyperexcitability disorders. However, collectively, these syndromes should be known as "anti-GAD positive neurological syndromes." An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.

[The stiff-person syndrome: a brief review and report of two cases]

The stiff-person syndrome is a rare and progressive neuromuscular disease which appears to have an immunpathological basis. It is characterised by painful muscle spasms and stiffness in the proximal muscles, especially those attached to the axial skeleton. The precise pathophysiology is still unknown, but several antibodies have been shown to be present in patients and these antibodies are directed against proteins which play a role in the inhibitor synapse linked to gamma-amino-butyrate. In the first part of the article the authors present two cases. In the second part they present a comprehensive review of our current knowledge about this rare disease. Orv.Hetil., 154(50), 1984-1990.

High-Yield Production in Escherichia coli of Fungal Immunomodulatory Protein Isolated from Flammulina velutipes and Its Bioactivity Assay in Vivo

A fungal immunomodulatory protein isolated from Flammulina velutipes (FIP-fve) has structural similarity to the variable region of the immunoglobulin heavy chain. In the present study, the recombinant bioactive FIP-fve protein with a His-tag in N-terminal of recombinant protein was expressed in transetta (DE3) at a high level under the optimized culturing conditions of 0.2 mM IPTG and 28 °C. The efficiency of the purification was improved with additional ultrasonication to the process of lysozyme lysis. The yield of the bioactive FIP-fve protein with 97.1% purity reached 29.1 mg/L with a large quantity for industrial applications. Enzyme-linked immunosorbent assay showed a maximum increase in interleukin-2 (IL-2) and gamma interferon (IFN-γ) for the mice serum group of 5 mg/kg body mass (p < 0.01) with three doses of His-FIP-fve. However, the production of IL-4 had no apparent difference compared to the control.

Physical therapist management of stiff person syndrome in a 24-year-old woman

BACKGROUND AND PURPOSE

Stiff person syndrome is a rare neurological disorder characterized by stiffness and painful spasms primarily in the trunk and lower extremities. The role of physical therapy in the management of this disorder is disputed and the efficacy of specific interventions is unknown.

CASE DESCRIPTION

The patient was a 24-year-old woman with a 1-year history of stiff person syndrome who received outpatient physical therapy over the course of 15 weeks. She had pain, muscle spasms, gait anomalies, and range-of-motion deficits, which affected her left lower extremity. Physical therapy interventions consisted of ultrasound, soft tissue mobilizations, manual stretching, and exercise. She also was fitted for a custom-made ankle-foot orthosis. Outcome This patient showed decreased pain and muscle spasms, as well as improvements in gait and range of motion.

DISCUSSION

Stiffness and spasms interfere with the ability of these patients to fully mobilize affected joints, and they are at risk of developing further complications. Physical therapy may have a role in the management of this disease, as these patients need to be taught how to properly stretch and maintain joint mobility as a lifelong commitment.

A critical update on the immunopathogenesis of Stiff Person Syndrome

BACKGROUND

Stiff Person Syndrome (SPS) is a relatively rare but often overlooked autoimmune neurological disorder that targets antigens within the brain's inhibitory pathways resulting in incapacitating stiffness and spasms that impact on the patients' quality of life. Although a number of immunomodulating therapies significantly improve the patients' symptoms, the exact pathogenic mechanisms remain unclear.

MATERIALS AND METHODS

The current literature on SPS was reviewed and combined with the authors' experience with many patients and various laboratory studies. The majority of the patients have high-titre anti-GAD (Glutamic Acid Decarboxylase) antibodies in the sera and CSF suggesting dysfunction of the GABAergic neurotransmission. These antibodies are excellent disease markers but their pathogenic role remains uncertain.

CONCLUSIONS

This review provides a critical assessment on the immunobiology of SPS, describes the identification of anti-GABARAP antibodies as a new antigenic target in the GABAergic synapse and identifies the areas for future research.

Scleritis in a Person with Stiff-Person Syndrome

PURPOSE

To describe a case of anterior scleritis in a patient with stiff-person syndrome.

METHODS

Case report.

RESULTS

A 55-year-old woman with stable stiff-person syndrome and off immunomodulatory therapy developed unilateral anterior scleritis, which resolved over three weeks with systemic nonsteroidal anti-inflammatory therapy.

CONCLUSIONS

The authors are unaware of reports regarding the association of scleritis with stiff-person syndrome.

Antibody therapy (IVIG): evaluation of the use of genomics and proteomics for the study of immunomodulation therapeutics

BACKGROUND AND OBJECTIVES

Intravenous immunoglobulin (IVIG) is used for an increasingly diverse number of therapeutic applications as an immunomodulation drug. Although it has demonstrated therapeutic effectiveness, the mechanism of action of IVIG in these disorders is poorly understood; this lack of understanding complicates rational clinical application and reimbursement for 'off-label' use.

MATERIALS AND METHODS

Selected literature on the clinical use of IVIG as an immunomodulation drug is reviewed. We present a brief description of DNA microarray and protein microarray technology and the application of such technologies to the study of immune system cells. The several studies on the application of DNA microarray technology to study gene expression in response to IVIG are presented.

RESULTS

There is increasing data on the use of DNA microarray and protein microarray technology to study gene expression in immune system cells including T cells, B cells, macrophages, and leucocytes. There is less information on the effect of IVIG on gene expression in immune system cells. However, there is sufficient information available to suggest that this is a practical approach with the caveat that such work will require careful experimental design and clear definition of the normal population.

CONCLUSIONS

DNA and protein microarray assays can be used to (i) provide rational indications for the clinical use of IVIG, (ii) provide for specific analysis of raw material and end product IVIG in screening for content related to immunomodulation, and (iii) accelerate the development of next generation products which would be more focused and/or targeted therapeutics.

Physical Therapy During In-Patient Rehabilitation for a Patient with Stiff-Person Syndrome

BACKGROUND AND PURPOSE

Patients with Stiff-Person Syndrome (SPS) typically show stiffness and spasms, primarily of the trunk and proximal lower extremities. The purpose of this case report is to provide an overview of SPS and a description of the specific physical therapy management strategies used during a brief inpatient rehabilitation stay for a patient with SPS, illustrating the use of the patient/client management model in the Guide to Physical Therapist Practice.

CASE DESCRIPTION

The patient was a 33-year-old with a 3- year history of SPS. He spent 10 days in an in-patient rehabilitation hospital where he received physical therapy daily. The initial examination revealed impairments of pain, range of motion, reflex integrity, and motor function, along with abnormalities of posture, balance, and function. The procedural interventions included therapeutic exercise and functional retraining. Stretching exercises were categorized according to their priority and level of difficulty to accommodate for the patient's varying symptoms, and relaxation exercises aimed to reduce the severity of the patient's spasms. The functional retraining program included transfer and progressive gait training.

OUTCOMES

The patient showed improvements in ankle range of motion, posture, and gait (distance, speed, and independence), despite continued problems with stiffness, spasms, and pain.

DISCUSSION

Physical therapists working with patients with SPS have challenges related to the paucity of information in the literature. The chronic, progressive, and variable nature of SPS indicates the need for life-long management, with the inclusion of an exercise program that can be adjusted accordingly, given the frequently changing symptoms experienced by the patient. As is shown with this case, it appears that physical therapy can improve function and some of the impairments associated with SPS.

Graves’ Disease and Stiff-Person (Stiff-Man) Syndrome: Case Report and Literature Review

OBJECTIVE

To report an association between two autoimmune conditions, Graves' disease and stiff-person (stiff-man) syndrome, and discuss the relevant literature.

METHODS

We present a case of a 52-year-old white woman with stiff-person syndrome who also had Graves' disease, discuss her management, and review the related literature. Pertinent published reports from 1950 through 2004 were researched with use of MEDLINE and PubMed, and cross-references to other articles were reviewed.

RESULTS

A 52-year-old white woman presented with symptoms of hyperthyroidism due to Graves' disease. Laboratory data were as follows: thyrotropin <0.005 m IU/mL, thyroxine 11.1 microg/dL, free thyroxine index (FTI) 10.7, and triiodothyronine 170 ng/dL. Thyroid-stimulating immunoglobulins (TSI) and thyrotropin-binding inhibitory immunoglobulins (TBII) were positive at 1,986% and 82.5 U/L, respectively. The hyperthyroidism was treated with propranolol. She had a long-standing history of musculoskeletal complaints and was ultimately diagnosed with stiff-person syndrome. During her thyroid evaluation, she had severe neurologic deterioration that necessitated hospitalization and treatment with clonazepam, baclofen, intravenous immunoglobulin, and subsequently prednisone and azathioprine for appreciable symptomatic relief. The aggressive immunosuppression had a profound effect on her symptoms of hyperthyroidism, results of thyroid function tests, and thyrotropin receptor antibodies (TRABs). Thyrotropin was 0.52 microIU/mL, thyroxine was 6.9 microg/dL, and FTI was 5.7. The TSI decreased from 1,986% to 248%, and her TBII normalized from 82.5 U/L to <5 U/L. She was clinically and biochemically euthyroid at last follow-up in May 2004.

CONCLUSION

This case illustrates the association between TRAB-positive Graves' disease and stiff-person syndrome and the improvement of Graves' disease with immunosuppressive therapy.

Paraneoplastic stiff-person syndrome: passive transfer to rats by means of IgG antibodies to amphiphysin

BACKGROUND

Stiff-person syndrome (SPS) with antibodies to amphiphysin is a paraneoplastic disorder of the central nervous system with a putative autoimmune pathogenesis. Proof of a causal role of the antibodies is still lacking for this and all other antibody-associated paraneoplastic syndromes of the central nervous system.

METHODS

We obtained the plasma filtrate of a patient with breast cancer and SPS that responded to therapeutic plasmapheresis. The purified IgG fraction included high-titre antibodies to the synaptic protein amphiphysin. In a cotransfer design, this IgG fraction was injected intraperitoneally into female Lewis rats that had received encephalitogenic T-helper (Th) lymphocytes specific for myelin basic protein, to induce an immune-mediated leaky blood-brain barrier. The rats were followed up with behavioural tests, video photography, and electromyography.

FINDINGS

The injection of the IgG fraction including antibodies to amphiphysin resulted in a dose-dependent stiffness with spasms resembling human SPS. Control IgG injected into rats that had received the same encephalitogenic Th cells had no effect. IgG binding was demonstrated in the central nervous system of rats that showed signs of the disorder.

INTERPRETATION

These experiments support the hypothesis of a pathogenetic role of antibodies to amphiphysin, thus adding paraneoplastic SPS to the group of antibody-mediated autoimmune disorders.

RELEVANCE TO PRACTICE

These findings provide a strong argument for a direct pathogenetic role of anti-amphiphysin in this type of SPS and support therapeutic attempts to eliminate these autoantibodies by plasmapheresis. The experimental approach used could help to elucidate the role of autoantibodies in other paraneoplastic syndromes, such as SPS with antibodies to glutamic acid decarboxylase, and others including anti-Hu-associated subacute cerebellar degeneration and limbic encephalitis.

Stiff-Person Syndrome

BACKGROUND

Stiff-person syndrome (SPS) is a rare neurologic disorder with autoimmune features. It is characterized by progressive, severe muscle rigidity or stiffness most prominently affecting the spine and lower extremities.

REVIEW SUMMARY

Superimposed muscle spasms result in simultaneous contraction of agonist and antagonist muscles which are detectable by electromyography (EMG) and relieved by administration of benzodiazepines. The exacerbation of SPS by emotional stressors often results in the referral of these patients for psychiatric assessment although this was more common before the discovery of an association with antibodies to glutamic acid decarboxylase (GAD antibodies). Formerly known as stiff-man syndrome, the female to male ratio is 2:1 and the principle paraneoplastic variant is associated with breast cancer. Although rare, this is a disease of middle age that severely curtails the functional capacity of those it strikes. It is frequently associated with diabetes and other autoimmune diseases. IVIg is recently demonstrated to be effective in the treatment of SPS; diazepam remains useful in managing the symptoms.

CONCLUSIONS

This article summarizes the history of SPS, describes important clinical features, discusses management, touches upon areas of uncertainty, and postulates some avenues for research.

Stiff person syndrome and anesthesia: case report

IMPLICATIONS

This case report describes the successful perioperative management of a patient with a rare and disabling neurologic disorder, the stiff person syndrome. The patient had a delayed emergence despite apparent full reversal of neuromuscular blockade. We suggest an interaction between the GABAergic effects of baclofen and volatile anesthetics as a possible cause.