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Canny E, Vansteensel MJ, van der Salm SMA, Müller-Putz GR, Berezutskaya J. Boosting brain-computer interfaces with functional electrical stimulation: potential applications in people with locked-in syndrome. J Neuroeng Rehabil 2023; 20:157. [PMID: 37980536 PMCID: PMC10656959 DOI: 10.1186/s12984-023-01272-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/23/2023] [Indexed: 11/20/2023] Open
Abstract
Individuals with a locked-in state live with severe whole-body paralysis that limits their ability to communicate with family and loved ones. Recent advances in brain-computer interface (BCI) technology have presented a potential alternative for these people to communicate by detecting neural activity associated with attempted hand or speech movements and translating the decoded intended movements to a control signal for a computer. A technique that could potentially enrich the communication capacity of BCIs is functional electrical stimulation (FES) of paralyzed limbs and face to restore body and facial movements of paralyzed individuals, allowing to add body language and facial expression to communication BCI utterances. Here, we review the current state of the art of existing BCI and FES work in people with paralysis of body and face and propose that a combined BCI-FES approach, which has already proved successful in several applications in stroke and spinal cord injury, can provide a novel promising mode of communication for locked-in individuals.
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Affiliation(s)
- Evan Canny
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mariska J Vansteensel
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sandra M A van der Salm
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gernot R Müller-Putz
- Institute of Neural Engineering, Laboratory of Brain-Computer Interfaces, Graz University of Technology, Graz, Austria
| | - Julia Berezutskaya
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.
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2
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Fournier CN. Considerations for Amyotrophic Lateral Sclerosis (ALS) Clinical Trial Design. Neurotherapeutics 2022; 19:1180-1192. [PMID: 35819713 PMCID: PMC9275386 DOI: 10.1007/s13311-022-01271-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 11/20/2022] Open
Abstract
Thoughtful clinical trial design is critical for efficient therapeutic development, particularly in the field of amyotrophic lateral sclerosis (ALS), where trials often aim to detect modest treatment effects among a population with heterogeneous disease progression. Appropriate outcome measure selection is necessary for trials to provide decisive and informative results. Investigators must consider the outcome measure's reliability, responsiveness to detect change when change has actually occurred, clinical relevance, and psychometric performance. ALS clinical trials can also be performed more efficiently by utilizing statistical enrichment techniques. Innovations in ALS prediction models allow for selection of participants with less heterogeneity in disease progression rates without requiring a lead-in period, or participants can be stratified according to predicted progression. Statistical enrichment can reduce the needed sample size and improve study power, but investigators must find a balance between optimizing statistical efficiency and retaining generalizability of study findings to the broader ALS population. Additional progress is still needed for biomarker development and validation to confirm target engagement in ALS treatment trials. Selection of an appropriate biofluid biomarker depends on the treatment mechanism of interest, and biomarker studies should be incorporated into early phase trials. Inclusion of patients with ALS as advisors and advocates can strengthen clinical trial design and study retention, but more engagement efforts are needed to improve diversity and equity in ALS research studies. Another challenge for ALS therapeutic development is identifying ways to respect patient autonomy and improve access to experimental treatment, something that is strongly desired by many patients with ALS and ALS advocacy organizations. Expanded access programs that run concurrently to well-designed and adequately powered randomized controlled trials may provide an opportunity to broaden access to promising therapeutics without compromising scientific integrity or rushing regulatory approval of therapies without adequate proof of efficacy.
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Affiliation(s)
- Christina N Fournier
- Department of Neurology, Emory University, Atlanta, GA, USA.
- Department of Veterans Affairs, Atlanta, GA, USA.
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3
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Yokota K, Masuda M, Koga R, Uemura M, Koga T, Nakashima Y, Kawano O, Maeda T. Diaphragm pacing implantation in Japan for a patient with cervical spinal cord injury: A case report. Medicine (Baltimore) 2022; 101:e29719. [PMID: 35776996 PMCID: PMC9239610 DOI: 10.1097/md.0000000000029719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Traumatic cervical spinal cord injury (SCI) is a devastating condition leading to respiratory failure that requires permanent mechanical ventilation, which is the main driver of increased medical costs. There is a great demand for establishing therapeutic interventions to treat respiratory dysfunction following severe cervical SCI. PATIENT CONCERNS AND DIAGNOSIS We present a 24-year-old man who sustained a cervical displaced C2-C3 fracture with SCI due to a traffic accident. As the patient presented with tetraplegia and difficulty in spontaneous breathing following injury, he was immediately intubated and placed on a ventilator with cervical external fixation by halo orthosis. The patient then underwent open reduction and posterior fusion of the cervical spine 3 weeks after injury. Although the patient showed significant motor recovery of the upper and lower limbs over time, only a slight improvement in lung capacity was observed. INTERVENTIONS AND OUTCOMES At 1.5 years after injury, a diaphragmatic pacing stimulator was surgically implanted to support the patient's respiratory function. The mechanical ventilator support was successfully withdrawn from the patient 14 weeks after implantation. We observed that both the vital capacity and tidal volume of the patient were significantly promoted following implantation. The patient finally returned to daily life without any mechanical support. LESSONS The findings of this report suggest that diaphragmatic pacing implantation could be a promising treatment for improving respiratory function after severe cervical SCI. To our knowledge, this is the first SCI patient treated with a diaphragm pacing implantation covered by official medical insurance in Japan.
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Affiliation(s)
- Kazuya Yokota
- Department of Orthopaedic Surgery, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
- Departments of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- *Correspondence: Kazuya Yokota, Department of Orthopaedic Surgery, Japan Labor Health and Welfare Organization Spinal Injuries Center, 550-4 Igisu, Iizuka, Fukuoka 820-0053, Japan (e-mail: )
| | - Muneaki Masuda
- Department of Orthopaedic Surgery, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
| | - Ryuichiro Koga
- Department of Rehabilitation Medicine, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
| | - Masatoshi Uemura
- Department of Rehabilitation Medicine, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
| | - Tadashi Koga
- Department of Surgery, Iizuka Hospital, Fukuoka, Japan
| | - Yasuharu Nakashima
- Departments of Orthopaedic Surgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Osamu Kawano
- Department of Orthopaedic Surgery, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
| | - Takeshi Maeda
- Department of Orthopaedic Surgery, Japan Labor Health and Welfare Organization Spinal Injuries Center, Fukuoka, Japan
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4
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Morélot-Panzini C, Nierat MC, Tanguy ML, Bruneteau G, Pradat PF, Salachas F, Gonzalez-Bermejo J, Similowski T. No Benefit of Diaphragm Pacing in Upper Motor Neuron-Dominant Forms of Amyotrophic Lateral Sclerosis. Am J Respir Crit Care Med 2019; 198:964-968. [PMID: 29957023 DOI: 10.1164/rccm.201803-0601le] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Capucine Morélot-Panzini
- 1 UMRS 1158 Inserm-Sorbonne Université Paris, France.,2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France
| | | | - Marie-Laure Tanguy
- 2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France.,3 Institut Curie Paris, France and
| | - Gaëlle Bruneteau
- 2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France.,4 UMRS 1127 Inserm-Sorbonne Université Paris, France
| | - Pierre-François Pradat
- 2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France.,4 UMRS 1127 Inserm-Sorbonne Université Paris, France
| | | | - Jésus Gonzalez-Bermejo
- 1 UMRS 1158 Inserm-Sorbonne Université Paris, France.,2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France
| | - Thomas Similowski
- 1 UMRS 1158 Inserm-Sorbonne Université Paris, France.,2 Groupe Hospitalier Pitié-Salpêtrière Charles Foix Paris, France
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5
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Niedermeyer S, Murn M, Choi PJ. Respiratory Failure in Amyotrophic Lateral Sclerosis. Chest 2018; 155:401-408. [PMID: 29990478 DOI: 10.1016/j.chest.2018.06.035] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/27/2018] [Accepted: 06/29/2018] [Indexed: 12/11/2022] Open
Abstract
Amyotrophic lateral sclerosis is a progressive neuromuscular disease characterized by both lower motor neuron and upper motor neuron dysfunction. Although clinical presentations can vary, there is no cure for ALS, and the disease is universally terminal, with most patients dying of respiratory complications. Patients die, on average, within 3 to 5 years of diagnosis, unless they choose to undergo tracheostomy, in which case, they may live, on average, 2 additional years. Up to 95% of patients with ALS in the United States choose not to undergo tracheostomy; management of respiratory failure is therefore aimed at both prolonging survival as well as improving quality of life. Standard of care for patients with ALS includes treatment from multidisciplinary teams, but many patients do not have consistent access to a pulmonary physician who regularly sees patients with this disease. The goal of this review was to serve as an overview of respiratory considerations in the management of ALS. This article discusses noninvasive ventilation in the management of respiratory muscle weakness, mechanical insufflation/exsufflation devices for airway clearance, and treatment of aspiration, including timing of placement of a percutaneous endoscopic gastrostomy tube, as well as secretion management. In addition, it is important for physicians to consider end-of-life issues such as advanced directives, hospice referral, and ventilator withdrawal.
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Affiliation(s)
- Shannon Niedermeyer
- Duke University Hospital, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Michael Murn
- Duke University Hospital, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Philip J Choi
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, University of Michigan Medical Center, Ann Arbor, MI.
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Karacam V, Sanli A, Tertemiz KC, Ulugun I. A practical technique in laparoscopic diaphragm pacing surgery: Retrospective analyse of 43 patients. J Minim Access Surg 2018; 14:273-276. [PMID: 29319015 PMCID: PMC6130177 DOI: 10.4103/jmas.jmas_165_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Diaphragm pacing stimulation (DPS) is a treatment method used in respiratory failure occurs in diseases such as high-level cervical spinal cord injury, central hypoventilation syndrome and amyotrophic lateral sclerosis. Materials and Methods: A total of 43 patients, who had undergone DPS implantation surgery were evaluated retrospectively. The patients were divided into two groups according to the surgical technique (Group 1: classical surgical technic and Group 2: modified surgical technic) applied. The patients with previous abdominal surgery or percutaneous endoscopic gastrostomy were excluded from the study. Results: The mean operation duration was significantly shorter in modified DPS implantation technic (105.1 min in Group 1 and 87.4 min in Group 2) (P < 0.001). Capnothorax is seen 11% of the cases in classical surgery procedure. In the modified group, capnothorax was not observed. Pneumothorax rate was found similar in both groups. Post-operative atelectasis was determined 16% of the cases in classical surgery procedure and also in the modified group atelectasis was not observed. The complications were higher in classical surgery procedure group but not differed statistically in this study. Total hospitalisation duration was significantly shorter in the modified surgical technique group compared to the other group (8.0 days in Group 1 and 6.0 days in Group 2) (P = 0.03). Conclusion: With modification in DPS implantation surgery, shorter operation and hospitalisation durations, and less complications may be achieved.
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Affiliation(s)
- Volkan Karacam
- Department of Thoracic Surgery, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey
| | - Aydin Sanli
- Department of Thoracic Surgery, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey
| | - Kemal Can Tertemiz
- Department of Pulmonary Diseases, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey
| | - Ilknur Ulugun
- Department of Thoracic Surgery, Medical Faculty, Dokuz Eylul University, Izmir 35340, Turkey
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Şanlı A, Şengün IŞ, Karaçam V, Alpaydın AÖ, Tertemiz KC, Özalevli S, Şanlı BA, Kaya A, Özdemir N. Preoperative parameters and their prognostic value in amyotrophic lateral sclerosis patients undergoing implantation of a diaphragm pacing stimulation system. Ann Indian Acad Neurol 2017; 20:51-54. [PMID: 28298842 PMCID: PMC5341268 DOI: 10.4103/0972-2327.192388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction: Amyotrophic lateral sclerosis (ALS) is a progressive neuromuscular disease with devastating and fatal respiratory complications. Diaphragm pacing stimulation (DPS) is a treatment option in diaphragm insufficient ALS patients. Ventilatory insufficiency depending on diaphragmatic failure is treated by the present study aimed to investigate prognostic value of preoperative clinical and functional characteristics of ALS patients undergoing implantation of a DPS system and to determine appropriate indications for the DPS system. Methods: The study included 34 ALS patients implanted with DPS system. All patients underwent multidisciplinary and laboratory evaluations before the surgery. The laboratory examinations included pulmonary function tests and arterial blood gas analysis. Survival rates were recorded in a 2-year follow-up after the surgery. Results: Twenty-eight of 34 patients with ALS survived after a 2-year follow-up. These patients were younger than those who died and had the disease for a longer time; however, the differences were not significant. Both right and left hemidiaghragms were thicker in the survived patients (P < 0.0001 for each). Pulmonary function tests revealed no significant differences between the patients who survived. Arterial blood gas analysis demonstrated lower partial pressure of carbon dioxide in the survived patients (P = 0.025). Conclusions: DPS implantation was more efficacious in ALS patients with mild respiratory failure and thicker diaphragm. Predictors of long-term effectiveness of DPS system are needed to be addressed by large-scale studies.
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Affiliation(s)
- Aydın Şanlı
- Department of Thoracic Surgery, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Ihsan Şükrü Şengün
- Department of Neurology, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Volkan Karaçam
- Department of Thoracic Surgery, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Aylin Özgen Alpaydın
- Department of Chest Diseases, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Kemal Can Tertemiz
- Department of Chest Diseases, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Sevgi Özalevli
- Department of Physiotherapy and Rehabilitation, School of Physical Therapy and Rehabilitation, Dokuz Eylül University, Izmir, Turkey
| | - Bahar Ağaoğlu Şanlı
- Department of Thoracic Surgery, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
| | - Alper Kaya
- Turkish ALS-MNH Association, Izmir, Turkey
| | - Nezih Özdemir
- Department of Thoracic Surgery, Faculty of Medicine, Dokuz Eylül University, Izmir, Turkey
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8
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Gonzalez-Bermejo J, Morélot-Panzini C, Tanguy ML, Meininger V, Pradat PF, Lenglet T, Bruneteau G, Forestier NL, Couratier P, Guy N, Desnuelle C, Prigent H, Perrin C, Attali V, Fargeot C, Nierat MC, Royer C, Ménégaux F, Salachas F, Similowski T. Early diaphragm pacing in patients with amyotrophic lateral sclerosis (RespiStimALS): a randomised controlled triple-blind trial. Lancet Neurol 2016; 15:1217-1227. [PMID: 27751553 DOI: 10.1016/s1474-4422(16)30233-2] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder associated with respiratory muscle weakness and respiratory failure. Non-invasive ventilation alleviates respiratory symptoms and prolongs life, but is a palliative intervention. Slowing the deterioration of diaphragm function before respiratory failure would be desirable. We aimed to assess whether early diaphragm pacing could slow down diaphragm deterioration and would therefore delay the need for non-invasive ventilation. METHODS We did a multicentre, randomised, controlled, triple-blind trial in patients with probable or definite ALS in 12 ALS centres in France. The main inclusion criterion was moderate respiratory involvement (forced vital capacity 60-80% predicted). Other key eligibility criteria were age older than 18 years and bilateral responses of the diaphragm to diagnostic phrenic stimulation. All patients were operated laparoscopically and received phrenic stimulators. Clinicians randomly assigned patients (1:1) to receive either active or sham stimulation with a central web-based randomisation system (computer-generated list). Investigators, patients, and an external outcome allocation committee were masked to treatment. The primary outcome was non-invasive ventilation-free survival, analysed in the intention-to-treat population. Safety outcomes were also assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01583088. FINDINGS Between Sept 27, 2012, and July 8, 2015, 74 participants were randomly assigned to receive either active (n=37) or sham (n=37) stimulation. On July 16, 2015, an unplanned masked analysis was done after another trial showed excess mortality with diaphragm pacing in patients with hypoventilation (DiPALS, ISRCTN 53817913). In view of this finding, we analysed mortality in our study and found excess mortality (death from any cause) in our active stimulation group. We therefore terminated the study on July, 16, 2015. Median non-invasive ventilation-free survival was 6·0 months (95% CI 3·6-8·7) in the active stimulation group versus 8·8 months (4·2-not reached) in the control (sham stimulation) group (hazard ratio 1·96 [95% CI 1·08-3·56], p=0·02). Serious adverse events (mainly capnothorax or pneumothorax, acute respiratory failure, venous thromboembolism, and gastrostomy) were frequent (24 [65%] patients in the active stimulation group vs 22 [59%] patients in the control group). No treatment-related death was reported. INTERPRETATION Early diaphragm pacing in patients with ALS and incipient respiratory involvement did not delay non-invasive ventilation and was associated with decreased survival. Diaphragm pacing is not indicated at the early stage of the ALS-related respiratory involvement. FUNDING Hospital Program for Clinical Research, French Ministry of Health; French Patients' Association for ALS Research (Association pour la Recherche sur la Sclérose Latérale Amyotrophique); and Thierry de Latran Foundation.
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Affiliation(s)
- Jésus Gonzalez-Bermejo
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France.
| | - Capucine Morélot-Panzini
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Marie-Laure Tanguy
- AP-HP, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Unité de Recherche Clinique, Paris, France
| | - Vincent Meininger
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Pierre-François Pradat
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - Timothée Lenglet
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Gaëlle Bruneteau
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, Institut du Cerveau et de la Moëlle Epinière, ICM, Paris, France
| | - Nadine Le Forestier
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | | | - Nathalie Guy
- CHU Gabriel Montpied, Service de Neurologie, Clermont-Ferrand, France; Faculté de Chirurgie Dentaire, Neuro-Dol, INSERM U1107, Douleur Trigéminale et Migraine, Clermont-Ferrand, France
| | | | - Hélène Prigent
- AP-HP, GHU Paris Ouest-site Raymond Poincaré-Service de Physiologie et d'Explorations Fonctionnelles, Garches, France
| | | | - Valérie Attali
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié Salpêtrière Charles Foix, Service des Pathologies du Sommeil (Département "R3S"), Paris, France
| | - Catherine Fargeot
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service Pharmacie UFDMS, Paris, France
| | - Marie-Cécile Nierat
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Catherine Royer
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Département d'Anesthésie et Réanimation, Paris, France
| | - Fabrice Ménégaux
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Chirurgie Viscérale, Paris, France
| | - François Salachas
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Centre de Référence Maladies Rares SLA, Département des Maladies du Système Nerveux, Paris, France
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
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9
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McDermott CJ, Bradburn MJ, Maguire C, Cooper CL, Baird WO, Baxter SK, Cohen J, Cantrill H, Dixon S, Ackroyd R, Baudouin S, Bentley A, Berrisford R, Bianchi S, Bourke SC, Darlison R, Ealing J, Elliott M, Fitzgerald P, Galloway S, Hamdalla H, Hanemann CO, Hughes P, Imam I, Karat D, Leek R, Maynard N, Orrell RW, Sarela A, Stradling J, Talbot K, Taylor L, Turner M, Simonds AK, Williams T, Wedzicha W, Young C, Shaw PJ. DiPALS: Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis - a randomised controlled trial. Health Technol Assess 2016; 20:1-186. [PMID: 27353839 DOI: 10.3310/hta20450] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease resulting in death, usually from respiratory failure, within 2-3 years of symptom onset. Non-invasive ventilation (NIV) is a treatment that when given to patients in respiratory failure leads to improved survival and quality of life. Diaphragm pacing (DP), using the NeuRx/4(®) diaphragm pacing system (DPS)™ (Synapse Biomedical, Oberlin, OH, USA), is a new technique that may offer additional or alternative benefits to patients with ALS who are in respiratory failure. OBJECTIVE The Diaphragm Pacing in patients with Amyotrophic Lateral Sclerosis (DiPALS) trial evaluated the effect of DP on survival over the study duration in patients with ALS with respiratory failure. DESIGN The DiPALS trial was a multicentre, parallel-group, open-label, randomised controlled trial incorporating health economic analyses and a qualitative longitudinal substudy. PARTICIPANTS Eligible participants had a diagnosis of ALS (ALS laboratory-supported probable, clinically probable or clinically definite according to the World Federation of Neurology revised El Escorial criteria), had been stabilised on riluzole for 30 days, were aged ≥ 18 years and were in respiratory failure. We planned to recruit 108 patients from seven UK-based specialist ALS or respiratory centres. Allocation was performed using 1 : 1 non-deterministic minimisation. INTERVENTIONS Participants were randomised to either standard care (NIV alone) or standard care (NIV) plus DP using the NeuRX/4 DPS. MAIN OUTCOME MEASURES The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Secondary outcomes were patient quality of life [assessed by European Quality of Life-5 Dimensions, three levels (EQ-5D-3L), Short Form questionnaire-36 items and Sleep Apnoea Quality of Life Index questionnaire]; carer quality of life (EQ-5D-3L and Caregiver Burden Inventory); cost-utility analysis and health-care resource use; tolerability and adverse events. Acceptability and attitudes to DP were assessed in a qualitative substudy. RESULTS In total, 74 participants were randomised into the trial and analysed, 37 participants to NIV plus pacing and 37 to standard care, before the Data Monitoring and Ethics Committee advised initial suspension of recruitment (December 2013) and subsequent discontinuation of pacing (on safety grounds) in all patients (June 2014). Follow-up assessments continued until the planned end of the study in December 2014. The median survival (interquartile range) was 22.5 months (lower quartile 11.8 months; upper quartile not reached) in the NIV arm and 11.0 months (6.7 to 17.0 months) in the NIV plus pacing arm, with an adjusted hazard ratio of 2.27 (95% confidence interval 1.22 to 4.25; p = 0.01). CONCLUSIONS Diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure. FUTURE WORK It may be that certain population subgroups benefit from DP. We are unable to explain the mechanism behind the excess mortality in the pacing arm, something the small trial size cannot help address. Future research should investigate the mechanism by which harm or benefit occurs further. TRIAL REGISTRATION Current Controlled Trials ISRCTN53817913. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 45. See the HTA programme website for further project information. Additional funding was provided by the Motor Neurone Disease Association of England, Wales and Northern Ireland.
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Affiliation(s)
| | - Mike J Bradburn
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chin Maguire
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy L Cooper
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Wendy O Baird
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Susan K Baxter
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Judith Cohen
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Sheffield Clinical Trials Research Unit, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Dixon
- Health Economics and Decision Science, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Roger Ackroyd
- Sheffield Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Sheffield, UK
| | - Simon Baudouin
- Royal Victoria Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and the University of Newcastle, Newcastle upon Tyne, UK
| | - Andrew Bentley
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | - Stephen Bianchi
- Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Stephen C Bourke
- North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust and Newcastle University, North Shields, UK
| | - Roy Darlison
- Independent patient and public involvement representative, UK
| | - John Ealing
- Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Mark Elliott
- Leeds Teaching Hospitals NHS Trust, St James' University Hospital, Leeds, UK
| | - Patrick Fitzgerald
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Galloway
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | | | | | - Philip Hughes
- Plymouth Hospitals NHS Trust Peninsula Medical and Dental Schools, Plymouth, UK
| | - Ibrahim Imam
- South Devon Healthcare NHS Foundation Trust, Devon, UK
| | - Dayalan Karat
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Roger Leek
- Motor Neurone Disease Association, Birmingham, UK
| | - Nick Maynard
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Richard W Orrell
- The National Heart and Lung Institute, Imperial College London, London, UK
| | - Abeezar Sarela
- Leeds Teaching Hospitals NHS Trust, St James' University Hospital, Leeds, UK
| | | | - Kevin Talbot
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Lyn Taylor
- PAREXEL International Corporation, Sheffield, UK
| | | | - Anita K Simonds
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Tim Williams
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Wisia Wedzicha
- The National Heart and Lung Institute, Imperial College London, London, UK
| | - Carolyn Young
- Walton Centre for Neurology & Neurosurgery NHS Foundation Trust, Liverpool, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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Safety and efficacy of diaphragm pacing in patients with respiratory insufficiency due to amyotrophic lateral sclerosis (DiPALS): a multicentre, open-label, randomised controlled trial. Lancet Neurol 2015; 14:883-892. [PMID: 26234554 DOI: 10.1016/s1474-4422(15)00152-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/23/2015] [Accepted: 06/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Non-invasive ventilation is part of the standard of care for treatment of respiratory failure in patients with amyotrophic lateral sclerosis (ALS). The NeuRx RA/4 Diaphragm Pacing System has received Humanitarian Device Exemption approval from the US Food and Drug Administration for treatment of respiratory failure in patients with ALS. We aimed to establish the safety and efficacy of diaphragm pacing with this system in patients with respiratory muscle weakness due to ALS. METHODS We undertook a multicentre, open-label, randomised controlled trial at seven specialist ALS and respiratory centres in the UK. Eligible participants were aged 18 years or older with laboratory supported probable, clinically probable, or clinically definite ALS; stable riluzole treatment for at least 30 days; and respiratory insufficiency. We randomly assigned participants (1:1), via a centralised web-based randomisation system with minimisation that balanced patients for age, sex, forced vital capacity, and bulbar function, to receive either non-invasive ventilation plus pacing with the NeuRx RA/4 Diaphragm Pacing System or non-invasive ventilation alone. Patients, carers, and outcome assessors were not masked to treatment allocation. The primary outcome was overall survival, defined as the time from randomisation to death from any cause. Analysis was by intention to treat. This trial is registered, ISRCTN number 53817913. FINDINGS Between Dec 5, 2011, and Dec 18, 2013, we randomly assigned 74 participants to receive either non-invasive ventilation alone (n=37) or non-invasive ventilation plus diaphragm pacing (n=37). On Dec 18, 2013, the Data Monitoring and Ethics Committee (DMEC) recommended suspension of recruitment on the basis of overall survival figures. Randomly assigned participants continued as per the study protocol until June 23, 2014, when the DMEC advised discontinuation of pacing in all patients. Follow-up assessments continued until the planned end of the study in December, 2014. Survival was shorter in the non-invasive ventilation plus pacing group than in the non-invasive ventilation alone group (median 11·0 months [95% CI 8·3-13·6] vs 22·5 months [13·6-not reached]; adjusted hazard ratio 2·27, 95% CI 1·22-4·25; p=0·009). 28 (76%) patients died in the pacing group and 19 (51%) patients died in the non-invasive ventilation alone group. We recorded 162 adverse events (5·9 events per person-year) in the pacing group, of which 46 events were serious, compared with 81 events (2·5 events per person-year) in the non-invasive ventilation alone group, of which 31 events were serious. INTERPRETATION Addition of diaphragm pacing to standard care with non-invasive ventilation was associated with decreased survival in patients with ALS. Our results suggest that diaphragmatic pacing should not be used as a routine treatment for patients with ALS in respiratory failure. FUNDING The National Institute for Health Research Health Technology Assessment Programme; the Motor Neurone Disease Association of England, Wales, and Northern Ireland.
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Ahmed RM, Newcombe REA, Piper AJ, Lewis SJ, Yee BJ, Kiernan MC, Grunstein RR. Sleep disorders and respiratory function in amyotrophic lateral sclerosis. Sleep Med Rev 2015; 26:33-42. [PMID: 26166297 DOI: 10.1016/j.smrv.2015.05.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/07/2015] [Accepted: 05/20/2015] [Indexed: 12/11/2022]
Abstract
Sleep disorders in amyotrophic lateral sclerosis (ALS) present a significant challenge to the management of patients. Issues include the maintenance of adequate ventilatory status through techniques such as non-invasive ventilation, which has the ability to modulate survival and improve patient quality of life. Here, a multidisciplinary approach to the management of these disorders is reviewed, from concepts about the underlying neurobiological basis, through to current management approaches and future directions for research.
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Affiliation(s)
- Rebekah M Ahmed
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia.
| | - Rowena E A Newcombe
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia
| | - Amanda J Piper
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
| | - Simon J Lewis
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia; NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia
| | - Brendon J Yee
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
| | - Matthew C Kiernan
- Brain and Mind Research Institute and Department of Neurology Royal Prince Alfred Hospital, University of Sydney, Sydney, New South Wales, Australia
| | - Ron R Grunstein
- NHMRC Centre for Integrated Research and Understanding of Sleep (CIRUS), Woolcock Institute of Medical Research and NeuroSleep NHMRC Centre for Research Excellence, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Australia
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Shin JY, Lee KW. Diagnosis and management of amyotrophic lateral sclerosis. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2015. [DOI: 10.5124/jkma.2015.58.2.131] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Je-Young Shin
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kwang-Woo Lee
- Department of Neurology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Pinto S, Carvalho MD. Breathing new life into treatment advances for respiratory failure in amyotrophic lateral sclerosis patients. Neurodegener Dis Manag 2014; 4:83-102. [DOI: 10.2217/nmt.13.74] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
SUMMARY In the last three decades, improvements in respiratory management are responsible for increasing survival and improving quality of life for amyotrophic lateral sclerosis (ALS) patients. Nowadays, ALS patients with respiratory involvement are offered a support treatment other than the traditional respiratory palliative care. Knowledge about available respiratory support potentialities is essential for appropriate, customized and effective treatment of ALS, which should probably be started sooner than the conventional approach. There is evidence supporting that respiratory support has a larger impact than riluzole on survival. Noninvasive ventilation is essential in the treatment of ALS patients with respiratory involvement. In this article methods to determine respiratory failure in ALS, mechanical invasive and noninvasive ventilation, telemetry, diaphragm pacing, cough aids and respiratory exercise are reviewed, after a brief overlook of respiratory insufficiency in ALS.
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Affiliation(s)
- Susana Pinto
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
| | - Mamede de Carvalho
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, Faculty of Medicine, University of Lisbon, 1648-028 Lisbon, Portugal
- Neuroscience Department, Santa Maria Hospital, Lisbon, Portugal
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Gordon PH. Amyotrophic Lateral Sclerosis: An update for 2013 Clinical Features, Pathophysiology, Management and Therapeutic Trials. Aging Dis 2013; 4:295-310. [PMID: 24124634 PMCID: PMC3794725 DOI: 10.14336/ad.2013.0400295] [Citation(s) in RCA: 174] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2013] [Revised: 08/26/2013] [Accepted: 08/27/2013] [Indexed: 01/28/2023] Open
Abstract
Amyotrophic lateral sclerosis (ALS), first described by Jean-Martin Charcot in the 1870s, is an age-related disorder that leads to degeneration of motor neurons. The disease begins focally in the central nervous system and then spreads relentlessly. The clinical diagnosis, defined by progressive signs and symptoms of upper and lower motor neuron dysfunction, is confirmed by electromyography. Additional testing excludes other conditions. The disease is heterogeneous, but most patients die of respiratory muscle weakness less than 3 years from symptom-onset. Like other age-related neurodegenerative diseases, ALS has genetic and environmental triggers. Of the five to 10% of cases that are inherited, mutations have been discovered for a high proportion. In addition to genetic factors, age, tobacco use, and athleticism may contribute to sporadic ALS, but important etiologies are unidentified for most patients. Complex pathophysiological processes, including mitochondrial dysfunction, aggregation of misfolded protein, oxidative stress, excitotoxicity, inflammation and apoptosis, involve both motor neurons and surrounding glial cells. There is clinical and pathological overlap with other neurodegenerative diseases, particularly frontotemporal dementia. The mechanisms leading to disease propagation in the brain are a current focus of research. To date, one medication, riluzole, licensed in 1996, has been proved to prolong survival in ALS. Numerous clinical trials have so far been unable to identify another neuroprotective agent. Researchers now aim to slow disease progression by targeting known pathophysiological pathways or genetic defects. Current approaches are directed at muscle proteins such as Nogo, energetic balance, cell replacement, and abnormal gene products resulting from mutations. Until better understanding of the causes and mechanisms underlying progression lead to more robust neuroprotective agents, symptomatic therapies can extend life and improve quality of life. Palliative care programs such as hospice give emotional and physical support to patients and families throughout much of the disease course.
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Affiliation(s)
- Paul H. Gordon
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département des Maladies du Système Nerveux, Paris, France
- Northern Navajo Medical Center, Shiprock, NM 87420, USA
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