SfN: Ballet Improves Ataxia in MS

I bet your doctor will never suggest this solution for your ataxia from your stroke. It is too damned difficult to translate an intervention for MS to one for stroke.
http://www.medpagetoday.com/mastery-of-medicine/neurology-mastery-in-ms/61506?
A rehabilitative dance program based on classical ballet improved ataxia among multiple sclerosis (MS) patients in a pilot study, researchers reported here.
Among the six patients enrolled in the program, all had significant improvements on most measures of the International Cooperative Ataxia Rating Scale (ICARS), Citlali Lopez-Ortiz, PhD, of the University of Illinois at Urbana-Champaign, and colleagues reported at the Society for Neuroscience meeting here.
"Animal models have shown that exercise increases myelination," Lopez-Ortiz told MedPage Today. "We think this sort of more heavily loaded, whole body exercise might be pushing some of the mechanisms that are improving conduction in MS so that we see improved coordination and reduction in ataxia."
The benefit of exercise and rehabilitation has been established, but there has been little focus on improving agility and smoothness of movement in exercise interventions for those with MS, the researchers said.
So they developed a targeted exercise intervention based on classical ballet training with the goal of improving agility, balance, ataxia, and smoothness of movement in MS. The program relies on knowledge about the nature of motor impairment and sensory processing as well as on the whole body movement associated with conservatory training in classical ballet, Lopez-Ortiz said.
"We think dance is important because it uses music, and research has identified that there is an effect of entrainment facilitation of movement when a rhythm is given to you. Dance couples music and movement intrinsically. Also, classical ballet has a high cognitive demand, involving the entire body all the time. Of all possible forms of dance, it is the most demanding, but it creates the most dexterous people on the planet. It's a technique that has been developed over 500 years, and over that time people have been able to identify what really works in training the motor system."
The researchers enrolled six patients with MS, ages 49 to 65, with Expanded Disability Status Scale (EDSS) scores ranging from 4.5 to 6.5 -- indicating walking impairment -- into the 16 week pilot study that involved two hour long classes per week.
The primary investigator, who has a Bolshoi Ballet Academy Teacher Certification and neuromuscular rehabilitation expertise, led the classes.
Balance was assessed using the Mini-BESTest, and ataxia was measured on the International Cooperative Ataxia Rating Scale.
Smoothness of gait was measured by calculating s-indexes of 29 reflective markers placed on anatomical landmarks of the body in a 5 meter walk test.
Overall, the researchers found that gait smoothness significantly improved on all measures at all locations, including the upper arm, elbow, upper leg, and knee.
Patients also had a significant, 42%, improvement on the Mini-BESTest, which Lopez-Ortiz noted far surpassed results in the literature for other exercise interventions.
"Previous literature on exercise interventions in MS shows improvements of about 10% to 15% in balance and walking ability in early-stage disease," she told MedPage Today. "In this study, although it's a pilot and we're still collecting data, we see improvement of 42% in balance and walking ability combined."
The team also found a benefit for ataxia, with significant improvement on all measures of ICARS (including posture and gait and kinetic), with the exception of the oculomotor test.
Lopez-Ortiz noted that dance provides motivation, social interactions, emotional expression, music, and targeted physical tasks in a single program centered on movement rehabilitation. Also, the cost of dance is a fraction of that of traditional pharmacological interventions for MS, she pointed out.
Next steps include doing a larger clinical trial, as well as digging further into the potential mechanisms behind the benefits.
Lopez-Ortiz said that the team has also tested this dance program in children with cerebral palsy and adults with Parkinson's disease, and has seen improvements in movement quality as well as clinical improvements "that make a difference in peoples' lives. Most commonly, it improves balance, but it also improves measures of coordination and movement in general."

The study was supported by the National Multiple Sclerosis Society.
Lopez-Ortiz disclosed no financial relationships with industry.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  Society for Neuroscience Meeting

  Source Reference: Lopez-Ortiz C, et al "Ataxia rehabilitation in multiple sclerosis through a targeted dance class" SFN 2016; Abstract 533.16/BBB1.

Oromucosal Spray Improves Tough-to-Treat Spasticity in Patients With MS

I bet your doctor will never use this on your spasticity. I bet s/he never even hears about it. Time for you to educate your doctor again. $1000 an hour charge to your doctor sounds about right.It is cannabinoid based thus will never make it past our idiotic federal legislators having marijuana as a Class I drug.  Bet you have to go to Europe to try it.
http://www.docguide.com/oromucosal-spray-improves-tough-treat-spasticity-patients-ms?

: Presented at ECTRIMS

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• Multiple Sclerosis

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By Jill Stein
LONDON -- September 17, 2016 -- New data support the use of a cannabinoid-based oromucosal spray as an add-on option to treat multiple sclerosis (MS)-related resistant spasticity.
The results, which are drawn from a large sample of patients treated with the spray in everyday clinical practice in Europe, were presented here at the 32nd Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS).
Patrick Vermersch, MD, Universitaire de Lille, Lille, France, and colleagues collected data from 433 patients starting treatment with the spray at specialist centres in Italy, Norway, and Denmark.
The spray contains the active substances delta-9-tetrahydrocannabinol and cannabidiol (THC:CBD) at a ratio of 1:1.
The study aimed to augment the positive clinical findings from randomised clinical trials (RCTs) evaluating the spray.
All patients had moderate-to-severe MS spasticity and had not responded adequately to other anti-spasticity medications.
Effectiveness was measured by rates of treatment continuation and changes from baseline in scores on the spasticity numerical (0-10) rating scale (NRS) and the modified Ashworth scale (0-4).
After a 1-month trial period, patients who had achieved ≥20% improvement in their spasticity NRS score could continue.
Overall, 349 participants continued treatment with the spray beyond the first month visit, and 281 patients continued treatment beyond the third month visit.
Spasticity scores on all scales improved significantly improved in study completers at 3 months: 0-10 NRS (mean 6.9 to 5.4) and Ashworth scale (mean 2.6 to 2.3).
The usual 3-level categorical scale for the severity of spasticity (mild/moderate/severe) showed a marked reduction in severe cases from 37.2% to 12.9%.
The percentage of patients with no restrictions in their daily activities resulting from their spasticity was significantly reduced from 30.2% to 22.8%.
Roughly 20% of patients improved ≥30% on their NRS score.
Dr. Vermersch said that the results compare favourably with results from prior RCTs and observational studies.
Funding for this study was provided by Almirall S.A.
[Presentation title: Tetrahydrocannabinol + Cannabidiol Oromucosal Spray for Multiple Sclerosis-Resistant Spasticity on Daily Practice, New Data. Abstract P757]

The MS Foot Drop Study

We will never know if this approach would help in stroke because there will be no followup in stroke. But your doctor has the email address and phone number for the lead researcher so there is no reason not to get your foot drop protocol updated.
https://ahpscot.wordpress.com/2016/07/04/the-ms-foot-drop-study/

By Linda Renfrew,
Consultant Physiotherapist in MS, NHS Ayrshire and Arran
Physical activity has many known and well publicised health benefits. One of the cheapest and most effective ways of keeping active is good old WALKING! But what can we do to promote physical activity and how can we help those with mobility problems to be as active as possible?
For those living with MS around 75% have mobility problems and foot drop is a common occurrence. Foot drop is a symptom in MS whereby the muscles of the lower leg no longer receive the messages from the brain and spinal cord telling them to lift the foot as the person takes a step when walking.
What does this mean? Why is it important? Well, for starters it means that the person has to compensate for foot drop and often ends up working harder to clear the foot from the ground. This sometimes causes hip and back pain, and it increases the likelihood of tripping and falling. Confidence in walking also slips and this makes it less likely that people with MS will keep physically active. The consequence of falls and inactivity also has cost and resource implications for the NHS.
Working as a physiotherapist in MS I had used some of the treatments available for foot drop; but there was limited evidence to tell me which of them were most effective for my patients. In 2014 myself and a team of experts from NHS Ayrshire & Arran, the University of Glasgow, Glasgow Caledonian University and Strathclyde University designed and got funding from the MS Society to start a study. The study which is based in the Douglas Grant Rehabilitation Centre is the first large scale randomised study to compare two treatments for foot drop: AFO (ankle foot orthosis) and FES (functional electrical stimulation).
Two years on we have 61 people with MS from across 7 health boards in Scotland who have taken part in the study. Health boards taking part include NHS Ayrshire & Arran, Dumfries & Galloway, Greater Glasgow and Clyde, Fife, Lanarkshire, Lothian and Tayside. We need to recruit a further 23 people (84 people in total) over the next 6 months so that we have results which are meaningful and which can influence how we treat foot drop in MS.
People with MS who are involved in the study come for 5 assessments over 12 months and receive either FES or AFO for their foot drop. Walking is assessed with and without the device over short and longer distances. We also use a gas analysis kit to measures how much oxygen is used during walking. This lets us see how efficient someone’s walking is. We use questionnaires to evaluate how the 2 devices affect how often someone falls, and whether their confidence in balance and walking and overall quality of life changes over the 12 months. We are measuring activity levels by using a small activity monitor taped to the thigh for 7 days.  Finally we are gathering information about treatment costs and peoples experience of both devices, so that all of our questions about these 2 treatments can be answered at the end of the study.
Since the beginning of this project we have been on such a journey making sure the study which spans 7 health boards runs to plan! If you are interested in finding out more about the study or our experiences so far, then drop us an email or give us a call:
Email: linda.renfrew@aapct.scot.nhs.uk
Telephone: 01294 323 057

Treating brain diseases with marijuana

And if we had anything even approaching a decent stroke association we would be researching the uses of marijuana for stroke. But we have crap instead. 
My reasons here;
My 13 reasons for marijuana use post-stroke. Don't follow me but I will figure out some way to get some after my next stroke.

 Treating brain diseases with marijuana

Multiple sclerosis sufferers may benefit from taking medical marijuana, according to a new study in the journal Neurology.

MS patients who used marijuana either as a pill or as an oral spray found relief from a number of symptoms, according to the study. The findings were released Monday at the annual meeting of the American Academy of Neurology (AAN).
"Medical marijuana can be considered to relieve particular symptoms of MS, including spasticity, pain related to spasms, or central pain from MS lesions," says Dr. Barbara Koppel, main author of the research analysis.
Koppel, a neurologist at New York Medical College in New York, says medical marijuana did not help MS patients who had tremors, nor did it relieve abnormal involuntary movements in late-stage Parkinson's disease. Researchers also didn't find enough evidence to recommend the treatment for other conditions they looked at, including epilepsy, she says.
Researchers looked at whether use of medical marijuana was safe and effective for other neurological diseases like motor symptoms in Huntington's disease, tics in Tourette's syndrome and cervical dystonia or abnormal neck movements. They decided there was not enough information to make a determination.
"Expected side effects such as fatigue, dizziness and nausea were found in the studies but rarely led to (people) dropping out of the study," says Koppel.
MS is an autoimmune disease affecting the brain and spinal cord. It's caused when the protective covering around the nerve cells is damaged by inflammation.  There is no single test for MS, nor is there a cure. There are several medications that can help slow down and control symptoms. The disease is usually diagnosed between the ages of 20 and 40 and more women are diagnosed than men.
Researchers looked at 34 different studies involving approximately 2,000 patients - the bulk of them in England and Germany. European regulators approved the cannabis spray Sativex for the treatment of MS spasticity in 2010, and it's now available in 25 countries worldwide. The drug is not available in the United States.
Less than 1% of trial participants taking cannabis pills or spray had serious side effects like hallucinations and seizures. In two of the studies analyzed, patients actually smoked marijuana, but there was not enough information available to determine if that was effective.
According to Koppel, medical marijuana can worsen cognitive function and memory. Her concern is that MS patients may already experience some of these issues as a result of the disease.
People with some of these diseases "already have higher rates of depression and suicidal ideation than the general public," Koppel says. "If you have a brain disease like MS, for example, you may already have some depression or cognitive impairment, so we were careful to see if cannabis made this worse."
While the studies did not find a direct link to depression, Koppel says it still suggests this is something patients and physicians should be aware of.
Dr. Timothy Coetzee, chief advocacy, services and research officer at the National MS Society, says his organization supports the rights of MS patients to work with their doctors to get access to medical marijuana in states where medical use has been legalized.
“The society supports the need for more research to better understand the benefits and potential risks of marijuana and its derivatives as a treatment for MS," Coetzee says. "We intend to work towards removing barriers impeding such research into the use of marijuana for medical purposes. As with any MS therapy, along with its potential benefits come potential side effects that also need to be evaluated.”
Koppel says more research is needed with more formulations of cannabis, not only in the diseases already looked at, but also in other neurologic conditions.

£1.1m study to reduce cognitive problems in people with MS

I can easily see being able to reuse this for stroke survivors. What is your doctor doing to follow this and create a cognitive stroke protocol for you? ANYTHING AT ALL?
http://www.alphagalileo.org/ViewItem.aspx?ItemId=151130&CultureCode=en
Experts in Nottingham are leading a major new study into how people with multiple sclerosis (MS) could overcome problems with attention and memory associated to their condition.
The Cognitive Rehabilitation for Attention and Memory in people with Multiple Sclerosis (CRAMMS) trial will evaluate the effectiveness of new strategies to improve and compensate for these difficulties and aims to improve the quality of life for the patient.
The trial is being led by Nadina Lincoln, Professor of Clinical Psychology in the Division of Rehabilitation and Ageing at The University of Nottingham and Dr Roshan das Nair, consultant clinical psychologist at Nottingham University Hospitals NHS Trust and honorary Associate Professor in the University’s Division of Rehabilitation and Ageing.
Funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, the trial will begin recruiting participants later this month.
Professor Lincoln said: “The purpose of our research is to help people with multiple sclerosis boost their everyday memory so they can get on with their lives and do the things that people take for granted, for example remembering to pick their children up from school, turning the stove off, or knowing where they have put things.
“It will also provide them with strategies to enable them to concentrate on information without getting distracted.”
Memory and attention problems are common complaints for those who have multiple sclerosis. More than 100,000 people in the UK have multiple sclerosis and of these, 50,000 will have problems with attention and memory at some stage in the progression of their condition.
Very few people with multiple sclerosis get treatment for cognitive problems in usual clinical practice, despite some evidence that cognitive rehabilitation may help reduce problems in attention and everyday forgetting. However, cognitive rehabilitation for people with multiple sclerosis has not been demonstrated to be effective or cost-effective in large-scale randomised controlled trials.
The study will be exploring the benefits of using internal memory aids, such as mnemonics — using patterns, words and images to remember details — and external aids, such as diaries, mobile phones and cameras. The researchers will also be looking for other imaginative ways to help improve memory and reduce forgetting.
The study is being conducted in collaboration with Swansea University, Nottingham University Hospitals NHS Trust, Sheffield Teaching Hospitals NHS Trust, The Walton Centre NHS Trust, and University Hospitals Birmingham NHS Trust.
They will recruit 400 volunteers, aged 16 to 69 years, from NHS hospitals, rehabilitation centres, multiple sclerosis charities, and web forums. About half the volunteers will then receive a 10-week group intervention at one of the study centres in Nottingham, Sheffield, Liverpool and Birmingham. The groups will focus on strategies to improve attention and to reduce memory problems in daily life. The remaining volunteers will continue to receive their existing level of care.
If this study confirms the benefits of cognitive rehabilitation it could lead to a change in clinical practice in the NHS and abroad. The researchers will also use questionnaires to determine the cost-effectiveness of this intervention, and to get feedback from those taking part in the trial to establish if intervention improved their quality of life.
http://www.nottingham.ac.uk/news/pressreleases/2015/march/11m-study-to-reduce-cognitive-problems-in-people-with-ms.aspx

Portable Neuromodulation Stimulator (PoNS) device

One of the chapters in Norman Doidges new book discusses this with respect to Parkinsons, stroke, and multiple sclerosis. You'll have to see what your doctor thinks on this and what protocols have been designed with its use in mind. More than likely your doctor has not heard of it.  Good luck.

Portable Neuromodulation Stimulator (PoNS) device

About The PoNS
The Portable Neuromodulation Stimulator (PoNS) device is an investigational medical device being studied for the treatment of neurological symptoms caused by disease or trauma. The PoNS is currently being studied in the United States for the treatment of balance disorder related to mild to moderate Traumatic Brain Injury (mTBI), and in Canada for the treatment of gait and balance disorder for patients with Multiple Sclerosis (MS). It represents the first in a series of non-invasive devices – based on the patented PoNS platform – designed to amplify the brain’s powerful ability to heal itself. This is part of a new approach being studied for symptom treatment for the rising number of patients who have experienced loss of function as a result of neurological disease or trauma.

Difference in motor fatigue between patients with stroke and patients with multiple sclerosis: a pilot study

What is your doctor doing to solve stroke fatigue?
Or is stroke fatigue once again somebody elses' problem to solve?
http://journal.frontiersin.org/Journal/10.3389/fneur.2014.00279/full?
Aida Sehle^1,2, Manfred Vieten¹, Annegret Mündermann^1,3 and Christian Dettmers^2,4*

• ¹Division of Sport Science, University of Konstanz, Konstanz, Germany
• ²Lurija Institute, Kliniken Schmieder Allensbach, Allensbach, Germany
• ³Department of Orthopaedics, University Hospital Basel, Basel, Switzerland
• ⁴Kliniken Schmieder Konstanz, Konstanz, Germany

Fatigue is often reported in stroke patients. However, it is still unclear if fatigue in stroke patients is more prominent, more frequent or more “typical” than in patients with multiple sclerosis (MS) and if the pathophysiology differs between these two populations. The purpose of this study was to compare motor fatigue and fatigue-induced changes in kinematic gait parameters between stroke patients, MS patients, and healthy persons. Gait parameters at the beginning and end of a treadmill walking test were assessed in 10 stroke patients, 40 MS patients, and 20 healthy subjects. The recently developed Fatigue index Kliniken Schmieder (FKS) based on change of the movement’s attractor and its variability was used to measure motor fatigue. Six stroke patients had a pathological FKS. The FKS (indicating the level of motor fatigue) in stroke patients was similar compared to MS patients. Stroke patients had smaller step length, step height and greater step width, circumduction with the right and left leg, and greater sway compared to the other groups at the beginning and at the end of test. A severe walking impairment in stroke patients does not necessarily cause a pathological FKS indicating motor fatigue. Moreover, the FKS can be used as a measure of motor fatigue in stroke and MS and may also be applicable to other diseases.

The representation of inflammatory signals in the brain – a model for subjective fatigue in multiple sclerosis

Would this possibly explain stroke fatigue? What is your doctor doing to solve stroke fatigue?
Or is stroke fatigue once again somebody elses' problem to solve?
http://journal.frontiersin.org/Journal/10.3389/fneur.2014.00264/full?

Katrin Hanken¹, Paul Eling² and Helmut Hildebrandt¹*

• ¹Department of Neurology, Klinikum Bremen-Ost, Bremen, Germany
• ²Donders Institute for Brain, Cognition and Behaviour, Radboud University Nijmegen, Nijmegen, Netherlands

In multiple sclerosis (MS) patients, fatigue is rated as one of the most common and disabling symptoms. However, the pathophysiology underlying this fatigue is not yet clear. Several lines of evidence suggest that immunological factors, such as elevated levels of pro-inflammatory cytokines, may contribute to subjective fatigue in MS patients. Pro-inflammatory cytokines represent primary mediators of immune-to-brain-communication, modulating changes in the neurophysiology of the central nervous system. Recently, we proposed a model arguing that fatigue in MS patients is a subjective feeling, which is related to inflammation. Moreover, it implies that fatigue can be measured behaviorally only by applying specific cognitive tasks related to alertness and vigilance. In the present review, we focus on the subjective feeling of MS-related fatigue. We examine the hypothesis that the subjective feeling of MS-related fatigue may be a variant of inflammation-induced sickness behavior, resulting from cytokine-mediated activity changes within brain areas involved in interoception and homeostasis including the insula, the anterior cingulate, and the hypothalamus. We first present studies demonstrating a relationship between pro-inflammatory cytokines and subjective fatigue in healthy individuals, in people with inflammatory disorders, and particularly in MS patients. Subsequently, we discuss studies analyzing the impact of anti-inflammatory treatment on fatigue. In the next part of this review, we present studies on the transmission and neural representation of inflammatory signals, with a special focus on possible neural concomitants of inflammation-induced fatigue. We also present two of our studies on the relationship between local gray and white matter atrophy and fatigue in MS patients. Finally, we discuss some implications of our findings and future perspectives.

Effect of Neurofeedback Training on Depression and Fatigue in Patients with Multiple Sclerosis

Will this work on stroke survivors? Curious minds want to know. A barely adequate stroke association would provide an answer. But since we won't get an answer from any stroke association I guess that answers the question on their competence.
http://link.springer.com/article/10.1007/s10484-014-9267-4

• Azadeh Choobforoushzadeh,
• Hamid Taher Neshat-Doost,
• Hossien Molavi,
• Mohammad Reza Abedi

$39.95 / €34.95 / £29.95 *

* Final gross prices may vary according to local VAT.

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Abstract

Depression and fatigue are common symptoms of multiple sclerosis (MS) and are the primary determinants of impaired quality of life in this demyelinating neurological disease. Untreated depression is associated with suicidal ideation, impaired cognitive function and poor adherence to immunomodulatory treatment. For these reasons, systematic screening and management of depressive symptoms and fatigue is recommended for all patients with MS. The objective of this study was to evaluate the effectiveness of neurofeedback in treating depression and fatigue in persons with MS. We conducted a randomized trial with 24 MS patients with primary fatigue and depression. Participants were randomized into two groups: neurofeedback training group (16 sessions of NFB) or treatment as usual. Participants were evaluated at 3 time points (baseline, end of the treatment, and 2-month follow-up) using the Fatigue Severity Scale and Depression subscale of the Hospital Anxiety and Depression Scale as outcome measures. A repeated measures analysis of variance was used to examine differences between the groups. NFB significantly reduced symptoms of depression and fatigue in patients with MS patients, compared to treatment as usual (p < .05), and these effects were maintained the 2-month follow-up (p < .05).

Management of fatigue in persons with multiple sclerosis

At least they have something. For stroke we have absolutely nothing. ASA, NSA, WSO are you going to step up to the plate and do the required research to solve the fatigue issue after stroke?
http://journal.frontiersin.org/Journal/10.3389/fneur.2014.00177/full?utm_source=newsletter&

Measuring Walk in MS, Cheaply and Efficiently

An objective way to measure your walking problems. I would expect your therapist to have this within a year because without this there is no way to objectively determine that your walking protocols are working.
http://www.medpagetoday.com/MeetingCoverage/ECTRIMS/47703?xid=nl_mpt_AAN_confreporter_2014-09-18&
Pressure sensitive walkways and motion tracking devices provided reliable and quantitative measures of ambulation in multiple sclerosis patients, researchers said here
Researchers often rely on either visual inspection or motion capturing technology to determine how well a patient is walking. But the former is often inaccurate, and the latter can be expensive, said Jacob Sosnoff, PhD, of the University of Illinois in Urbana-Champaign, in a presentation at the European Committee for Treatment and Research in Multiple Sclerosis, held jointly this year with its North American counterpart.
Sosnoff and colleagues analyzed the walk of 86 ambulatory patients 6 months apart using GAITRite, a portable walkway sensitive to pressure. GAITRite -- whose products sell for $25,000 to $35,000 depending on the model, according to the company -- has previously been tested. In the current study, the researchers evaluated its reliability -- that is, whether results are similar in multiple tests during which the person's actual performance would not have changed substantially -- using intraclass correlation coefficients (ICC), which range from -1 to the perfectly correlated 1.
Five measures of walking were found to be reliable using the system:

• Gait velocity: 0.94, 95% CI .84-.97
• Functional ambulation profile: 0.94, 95% CI 0.90-0.96
• Cadence: 0.94, 95% CI 0.83-0.97
• Step time: 0.94, 95% CI 0.91-0.97
• Double support: 0.75, 95% CI 0.60-0.85

"Ultimately, the goal is to help people," Sosnoff told MedPage Today. "And what was unique about this study is that we were using a time period of 6 months, which is how often someone would go to their neurologist or physical therapist." There was no intervention in between those 6 months, he said.
Of the patients in Sosnoff's study, 77% were female, and the median age was 50 (range 27-60). All of them had MS for at least six months, and 78% reported relapsing remitting MS. They had a self-reported disability of 3 on the patient determined disease steps scale (0-6). Patients were asked to walk 4.9 meters at their own pace on the GAITRite.
Walking impairment was reported as a primary limitation by 85% of study participants, said Sosnoff. "We want to target gait in rehabilitation, but obviously, for us to target that, we need to have valid and reliable measures."
Currently, functional abilities in MS patients are most often assessed with the Expanded Disability Status Scale (EDSS), a categorical measure that relies on subjective evaluations that may vary between raters, and yet is insensitive to small changes.
A continuous measure that is less subjective and that can be relied on to show genuine decreases or increases in functional ability over time would be useful both for clinical research and for routine patient management.
In a separate study, researchers used Microsoft Kinect -- a motion-sensing input device designed mainly for home video gaming -- to perform a postural control assessment. The $200 device was found to be reliable in measuring the impairment of MS patients using short stance tests, said Sebastian Mertens, a medical student at the NeuroCure Clinical Research Center-Charité in Berlin, Germany.
Mertens and his colleagues performed a cross-sectional study comparing 100 patients with MS with 60 healthy controls. The speed of three types of movements -- pitch, roll, and 3D -- was measured and compared with the Expanded Disability Status Scale (EDSS), a timed 25-foot walk (T25W), a short maximum speed walk test (SMSW), and the WALK-12 evaluation. Participants did an open stance, a closed stance, and a tandem stance (i.e., with one foot in front of the other).
Participants in the study performed the test once with closed eyes and once with open eyes. ICC values for the three movements were 0.927, 0.900, and 0.943, respectively, with eyes closed, and 0.968, 0.933, and 0.971, respectively, with eyes open. In the closed stance, the 3D speed correlated modestly with the other measures:

• EDSS: 0.458 (P<0.001, eyes open) and 0.531 (P<0.001, eyes closed)
• SMSW: -0.332 (P<0.001) and no correlation with closed eyes
• T25W: 0.318 (P<0.01, eyes open) and 0.331 (P<0.001, eyes closed)
• WALK12: 0.340 (P<0.001, eyes open) and 0.478 (P<0.001, eyes closed)

Obvious impairment was observed in 30% of the MS patients, who also showed values outside the 99th percentile in the test with eyes closed.
There were no significant correlations with a patient's age, height, or body mass index. In the closed stance, MS patients were also found to have higher compensatory arm movements with eyes closed (P=0.001) and open (P=0.013) than in the control group.
"Kinect-based postural control assessment is fast and feasible," the researchers concluded.

Sativex Helps MS Spasticity in Objective Tests

Is your doctor following current research at all and are they willing to try this on you as an off-label use? Or do they believe that you shouldn't bother about spasticity like Dr. William M. Landau suggests. And you'd have to go to Europe to get it because we have absolute f*cking idiots in Congress  about marijuana.

Spasticity After Stroke: Why Bother?

Sativex Helps MS Spasticity in Objective Tests 

An objectively measured sign of spasticity in multiple sclerosis (MS) patients was relieved with Sativex, the oromucosal cannabinoid spray, in a small randomized trial reported here.

Mean scores on the modified Ashworth scale, which measures resistance to muscular stretching, for lower limb spasticity improved by 18.2% (SD 33.7%) in patients treated with Sativex for 4 weeks, compared with a 6.7% improvement (SD 26.6%) in patients using a placebo spray (P=0.029 for the between-group difference), according to Letizia Leocani, MD, PhD, of University Hospital San Raffaele in Milan.
Previous studies had shown that Sativex, which combines tetrahydrocannabinol and cannabidiol in equal parts, improved MS patients' self-reported symptoms of spasticity. But a systematic review and practice guideline released earlier this year by the American Academy of Neurology indicated that the product is "probably ineffective" for objective spasticity measures.
Hence, the current study -- presented at the European Committee for Treatment and Research in Multiple Sclerosis, held jointly this year with its North American counterpart -- provides new support for Sativex as a useful treatment for MS spasticity, an important manifestation that contributes to disability.
It randomized 43 patients to a 2-week titration period followed by 2 weeks of treatment at stable doses with either placebo or Sativex. Following a 2-week washout period, patients then crossed over to a second 4-week cycle with the other treatment.
Exclusion criteria were other medical or psychiatric illnesses that might interfere with treatment or symptomatology, contraindications to transcranial magnetic stimulation, or THC urine test results indicating previous cannabis use.
Patients must have had progressive MS for at least 1 year and modified Ashworth scores at screening of greater than 1 in at least one limb.
Mean patient age in the study was 48 (SD 7) and mean score on the Expanded Disability Status Scale was 5.7 (SD 0.9, range 3.5 to 6.5).
In addition to modified Ashworth score, patients were evaluated with timed 10-meter walks and neurophysiological measures including motor evoked potentials, intracortical inhibition/facilitation, and the so-called H/M ratio (maximal Hoffmann reflex versus the maximal motor response of the soleus muscle).
A responder analysis showed that, among those achieving at least 20% improvement in modified Ashworth scores, half of participants showed such responses only when receiving Sativex. The remainder were divided among patients responding to both the active drug and placebo and those who only responded to placebo.
Importantly, however, Sativex did not produce significant improvements on outcomes other than the modified Ashworth score. In addition to the objective measures, these included patient-reported pain, sleep, and fatigue.
Leocani said these results indicated that additional research is needed on "the relevance of other spinal and supraspinal mechanisms involved in the physiopathology of spasticity."
Sativex is not approved in the U.S.; it is available in several European countries for relief of MS spasticity.

 

Demyelinating disease: What causes it?

Stroke isn't listed as one of the causes. I wonder what the exact damage is in your white matter when deprived of oxygen.  A neurologist I saw one time spouted off that I would recover no more function because by that time(2 years) the white matter connecting to left side muscles would have dymyelinated from nonuse. One of the reasons I think neurologists have got to be some of the stupidest doctors around.
http://www.mayoclinic.org/demyelinating-disease/expert-answers/faq-20058521/?

Multiple sclerosis

Multiple sclerosis (MS) is the most common demyelinating disease of the central nervous system. In this disorder, your immune system attacks the myelin sheath or the cells that produce and maintain it.
This causes inflammation and injury to the sheath and ultimately to the nerve fibers that it surrounds and may result in multiple areas of scarring (sclerosis).

Other causes

Other types of demyelinating disease and their causes include:

• Optic neuritis — inflammation of the optic nerve in one or both eyes
• Neuromyelitis optica (Devic’s disease) — inflammation and demyelination of the central nervous system, especially of the optic nerve and spinal cord
• Transverse myelitis — inflammation of the spinal cord
• Acute disseminated encephalomyelitis — inflammation of the brain and spinal cord
• Adrenoleukodystrophy and adrenomyeloneuropathy — rare, inherited metabolic disorders

MS and other demyelinating diseases most commonly result in vision loss, muscle weakness, muscle stiffness and spasms, loss of coordination, loss of sensation, pain, and changes in bladder and bowel function.

Treatment

No cures exist for demyelinating diseases and their progression, and symptoms are different for everyone.

Stroke Rounds: An MS Drug for ICH?

I bet your doctor will not attempt to use this until much more research is done. Making sure s/he kills off lots of neurons in the nneuronal cascade of death.   You wouldn't want to do anything innovative unless it has been studied to death, just like your neurons dying. What is the downside of this?
And why limit this to ICH?

Stroke Rounds: An MS Drug for ICH?

Patients with intracerebral hemorrhage (ICH) showed improved outcomes when given fingolimod (Gilenya), the oral multiple sclerosis drug, compared with standard care alone in a small trial, researchers said.
All those treated with fingolimod plus usual care in the 23-patient trial achieved Glasgow Coma Scale scores of 15 within a week, compared with 50% of those assigned to receive only standard therapy (P=0.01), according to Fu-Dong Shi, MD, PhD, of Tianjin Medical University General Hospital in Tianjin, China, and colleagues.
Other benefits associated with fingolimod treatment included better 1-week National Institutes of Health Stroke Scale (NIHSS) scores and improved scores on the Barthel index for neurological function and on the modified Rankin scale at 3 months, Shi and colleagues reported online in JAMA Neurology.
In addition, perihematomal edema (PHE) volumes were significantly reduced with fingolimod relative to standard care alone, the researchers indicated.
"The efficacy of fingolimod in preventing secondary brain injury in patients with ICH warrants further investigation in late-phase trials," Shi and colleagues wrote.
In an accompanying commentary, two U.S. researchers noted some limitations of the trial's design, but agreed with the overall conclusion and that the underlying hypothesis -- that fingolimod may temper inflammatory reactions responsible for many of the longer-term functional deficits in ICH -- has merit.
"The current study ... bolsters the case for this line of inquiry," wrote Kevin Sheth, MD, of Yale University, Conn., and Jonathan Rosand, MD, MSc, of Boston's Massachusetts General Hospital.
"Recent scientific advances confirm immunomodulation is plausible. Rigorous safety testing and adequately designed and powered clinical trials will be essential," they added.
Fingolimod, an inhibitor of the sphingosine-1-phosphate complex, blocks migration of activated T cells out of lymph nodes, thereby preventing them from entering the central nervous system (CNS).
Because the inflammatory cascade that results from ICH is at least partly driven by immune cells recruited from outside the CNS, Shi and colleagues hypothesized that fingolimod could reduce the scale of such reactions if given quickly after onset of bleeding within the brain.
For the current study, the researchers identified 23 patients with CT-confirmed ICH showing similar clinical characteristics. The first 12 were assigned to receive the standard of care only; the next 11 received the same care plus 0.5 mg/day oral fingolimod for 3 days. All patients in the fingolimod group started on the drug within 72 hours of symptom onset.
In addition to Glasgow Coma Score score at 7 days, outcome measures included the following:

• Glasgow score at 14 days
• NIHSS score at 7 and 14 days
• Modified Rankin score at 90 days
• Modified Barthel Index at 90 days
• Hematomal volume at 7 and 14 days
• PHE volume at 7 and 14 days
• Relative PHE volume at 7 and 17 days (PHE/hematomal volume)

At baseline, 42% of control patients and 18% of those receiving fingolimod had Glasgow scores of 15. The significantly better improvement with fingolimod relative to control seen at 7 days was sustained at day 14, Shi and colleagues reported.
NIHSS scores were similar in the two groups at baseline: 13.0 (SD 1.6) for controls and 15.6 (SD 1.8) in the fingolimod group. These decreased by a mean of 0.5 (SD 0.4) points during the first week in controls versus 7.5 (SD 1.0) points among patients treated with fingolimod (P<0.001). Subsequent decreases were small and similar over the following week, the researchers indicated.
Mean modified Rankin scores were in the range of 4.3-4.4 in both groups at baseline. On day seven, there was no change in control patients whereas the mean score decreased to 3.7 with fingolimod (P<0.001). On day 90, none of the control group had achieved Rankin scores of 1 or less, compared with 63% of the fingolimod group (P=0.001).
Findings were similar for Barthel Index scores, the researchers reported: 63% of the fingolimod group showed scores of 95-100 at day 90, versus none of the controls.
The analyses of hematomal and edema volumes indicated that the former's trajectories were similar between groups, with a slow decrease seen over the first 14 days. However, PHE values and the ratio of PHE to hematomal volume differed significantly. These values increased in both groups, but much more slowly in the fingolimod group.
In their commentary, Sheth and Rosand cautioned against putting too much stock in these latter findings. "Quantification of PHE can be inconsistent between magnetic resonance imaging and computed tomography, and the time from ictus to initial measurement appears to have been different between groups," they wrote.
Sheth and Rosand suggested that future research should focus on reliable measurement methods for post-ICH edema -- "a critical gap in knowledge," they asserted.

Brain reserve and cognitive reserve protect against cognitive decline over 4.5 years in MS

I bet the same theory would apply to surviving a stroke with better brain reserve.  Have your doctor measure your brain reserve and calculate how large a stroke you can survive.  Considering the size of mine I must have had a substantial reserve.
http://www.neurology.org/content/early/2014/04/18/WNL.0000000000000433.short

1. James F. Sumowski, PhD,
2. Maria A. Rocca, MD,
3. Victoria M. Leavitt, PhD,
4. Jelena Dackovic, MD,
5. Sarlota Mesaros, MD,
6. Jelena Drulovic, MD,
7. John DeLuca, PhD and
8. Massimo Filippi, MD

+Show Affiliations

| + Show Full Disclosures

1. Correspondence to Dr. Sumowski: jsumowski@kesslerfoundation.org

1. Published online before print April 18, 2014, doi: 10.1212/WNL.0000000000000433 Neurology 10.1212/WNL.0000000000000433

• Abstract
• Full Text (PDF)

1. Also available:
2. Data Supplement

Abstract

Objective: Based on the theories of brain reserve and cognitive reserve, we investigated whether larger maximal lifetime brain growth (MLBG) and/or greater lifetime intellectual enrichment protect against cognitive decline over time.

Methods: Forty patients with multiple sclerosis (MS) underwent baseline and 4.5-year follow-up evaluations of cognitive efficiency (Symbol Digit Modalities Test, Paced Auditory Serial Addition Task) and memory (Selective Reminding Test, Spatial Recall Test). Baseline and follow-up MRIs quantified disease progression: percentage brain volume change (cerebral atrophy), percentage change in T2 lesion volume. MLBG (brain reserve) was estimated with intracranial volume; intellectual enrichment (cognitive reserve) was estimated with vocabulary. We performed repeated-measures analyses of covariance to investigate whether larger MLBG and/or greater intellectual enrichment moderate/attenuate cognitive decline over time, controlling for disease progression.

Results: Patients with MS declined in cognitive efficiency and memory (p < 0.001). MLBG moderated decline in cognitive efficiency (p = 0.031, η_p² = 0.122), with larger MLBG protecting against decline. MLBG did not moderate memory decline (p = 0.234, η_p² = 0.039). Intellectual enrichment moderated decline in cognitive efficiency (p = 0.031, η_p² = 0.126) and memory (p = 0.037, η_p² = 0.115), with greater intellectual enrichment protecting against decline. MS disease progression was more negatively associated with change in cognitive efficiency and memory among patients with lower vs higher MLBG and intellectual enrichment.

Conclusion: We provide longitudinal support for theories of brain reserve and cognitive reserve in MS. Larger MLBG protects against decline in cognitive efficiency, and greater intellectual enrichment protects against decline in cognitive efficiency and memory. Consideration of these protective factors should improve prediction of future cognitive decline in patients with MS.

Summary of evidence-based guideline: Complementary and alternative medicine in multiple sclerosis - cannabis use

Of course, no one in the stroke world knows about this unless you tell your doctors. With this your doctor should have the legal ability to prescribe this since nothing else works for spasticity. But what the hell do I know?
http://www.neurology.org/content/82/12/1083.full
The appropriate stuff for us to know:
Results and recommendations: Clinicians might offer oral cannabis extract for spasticity symptoms and pain (excluding central neuropathic pain) (Level A). Clinicians might offer tetrahydrocannabinol for spasticity symptoms and pain (excluding central neuropathic pain) (Level B). Clinicians should counsel patients that these agents are probably ineffective for objective??? spasticity (short-term)/tremor (Level B) and possibly effective for spasticity and pain (long-term) (Level C). Clinicians might offer Sativex oromucosal cannabinoid spray (nabiximols) for spasticity symptoms, pain, and urinary frequency (Level B). Clinicians should counsel patients that these agents are probably ineffective for objective spasticity/urinary incontinence (Level B). Clinicians might choose not to offer these agents for tremor (Level C). Clinicians might counsel patients that magnetic therapy is probably effective for fatigue and probably ineffective for depression (Level B); fish oil is probably ineffective for relapses, disability, fatigue, MRI lesions, and quality of life (QOL) (Level B); ginkgo biloba is ineffective for cognition (Level A) and possibly effective for fatigue (Level C); reflexology is possibly effective for paresthesia (Level C); Cari Loder regimen is possibly ineffective for disability, symptoms, depression, and fatigue (Level C); and bee sting therapy is possibly ineffective for relapses, disability, fatigue, lesion burden/volume, and health-related QOL (Level C). Cannabinoids may cause adverse effects. Clinicians should exercise caution regarding standardized vs nonstandardized cannabis extracts and overall CAM quality control/nonregulation. Safety/efficacy of other CAM/CAM interaction with MS disease-modifying therapies is unknown.

Siddharthan Chandran: Can the damaged brain repair itself?

He is mainly talking about TBI, MS and ALS. What is completely disgusting is that I don't think there is a single person in the world that can answer that question for stroke.
http://www.ted.com/talks/siddharthan_chandran_can_the_damaged_brain_repair_itself.html?

Alemtuzumab in the treatment of multiple sclerosis

Since MS is the loss of the myelin sheath, does anyone know if that is one of the side effects of a stroke? Your doctor maybe? If so, would this be useful? And because we don't have a great stroke association to answer these simple questions we are screwed and may never know the answer.
I did have a neurologist tell me that once but I think he was blowing smoke out his ass, because I asked a question he didn't know the answer to.
http://www.dovepress.com/articles.php?article_id=15776

Authors: Fernandez Ó

Published Date February 2014 Volume 2014:7 Pages 19 - 27

DOI: http://dx.doi.org/10.2147/JIR.S38079

Received:	30 October 2013
Accepted:	25 November 2013
Published:	12 February 2014

Óscar Fernandez

Institute of Clinical Neuroscience, Neurology Department, Hospital Regional Universitario Carlos Haya, FIMABIS, Malaga, Spain

Abstract: Alemtuzumab (formerly known as Campath-1H) has recently been approved by the European Medicines Agency for highly-active, relapsing-remitting multiple sclerosis (MS). The molecule targets the CD52 surface glycoprotein on certain T cells and B cells and is thought to exert its effect in MS through a “resetting” of the lymphocyte population. Approval was granted on the strength of two pivotal studies, Comparison of Alemtuzumab and Rebif^® Efficacy in Multiple Sclerosis (CARE-MS)-1 in the first-line setting and CARE-MS-2 in patients who had failed first-line therapy. In both studies, alemtuzumab significantly reduced the relapse rate compared to the comparator, interferon beta-1a (44 µg) given subcutaneously three-times per week (Rebif^®). In the first-line study, alemtuzumab was also found to significantly reduce the number of patients with sustained progression compared to interferon beta-1a therapy. Autoimmune disorders represent the major side effect of alemtuzumab therapy although they can be managed by careful monitoring and early treatment. Overall, alemtuzumab is likely to be a valuable addition to the neurologist´s armamentarium for the treatment of relapsing-remitting MS.

Tapping Medical Marijuana’s Potential

A NYTimes Wellnes blog.
I include one sentence that your doctor should be figuring out a way around to help your spasticity. The stupidity of the Schedule I classification burns.
http://well.blogs.nytimes.com/2013/11/04/tapping-medical-marijuanas-potential/?_r=0
The strongest evidence for the health benefits of medical marijuana or its derivatives involves the treatment of chronic neuropathic pain and the spasticity caused by multiple sclerosis.  
(Who the hell is studying it for stroke spasticity?)
A great stroke association would do the research and contract it to be done in more enlightened countries and then work on changing the classification of the drug in the US. But that would require initiative and people that actually work for the best interests of stroke survivors. That doesn't include the ASA, NSA or WSO.

Suited for treatment of brain damage

Our great stroke association could figure out a way to eStim complicated muscle movements like walking, throwing a ball, etc.  You do expect this to be rolled out in the next couple of years, don't you? You could match it up with the Regent suit from Russia.

http://www.alphagalileo.org/ViewItem.aspx?ItemId=135393&CultureCode=en
For those with brain damage or neurological disorders - such as MS or Parkinson's - treatment could be as close as the wardrobe.
Improved range of motion and reduced pain for people with brain injuries and neurological disorders may now be available with a specially-designed elastic body suit fitted with electrodes, which was designed at Stockholm’s KTH Royal Institute of Technology in collaboration with health care and business partners.
The Mollii garment provides an alternative to painful treatments and surgery, by treating the body with electrical stimulation to ease tension and spasms. The result is reduced pain perception and increased mobility.
The idea originated with a Swedish chiropractor, Fredrik Lundqvist, who worked with rehabilitation of brain-damaged patients. Lundqvist struck upon the idea of sewing electrical stimuli – similar to TENS (transcutaneous electrical nerve stimulation) electrodes – into garments that the patient can wear.
He turned to KTH researchers Johan Gawell and Jonas Wistrand at the Department of Machine Design at KTH. “They produced a prototype of the product, and today they are working full time on the development of Mollii,” Lundqvist says.
Designed with ordinary swimsuit material, the body suit has conductive elastic sewn into it, with electrodes located at the major muscles.
Battery-powered light current is conducted via silver wires to 58 electrodes attached to the inside of the garment, which in turn stimulate as many as distinct 42 muscles, according to the patient’s needs.
Batteries are placed in a small control box fitted at the waistband.
“The idea is that the clothes should be used for a few hours, three times a week, and the effect is expected to last for up to two days,” Lundqvist says.
Users are advised engage in movement through training and stretching during the treatment.
“To enhance the quality of life the patient may choose to use Mollii before it's time to go to work, school or to a social event. That enables the body to function as well as possible when it is really needed,” he says.
The garment has been shown to be highly effective in patient examinations performed in collaboration with a PhD student Stockholm’s Karolinska Institute, Lundvist says. “One-hundred percent of the participants in the survey say they have experienced improvements in existing function or quality of life,” he says.
Stroke patients with paralysis on one side have been found to gain increased mobility in spastic limbs, in that they had improved gait and their arms and hands worked better after treatment.
“As a bonus, the patients often sleep better, and their pharyngeal motor skills and speech improved after using Mollii,” Lundqvist says.
“It can also help children with physical disabilities or motor difficulties in the feet, such as constantly walking on toes or with their feet at inward angles,” Lundqvist says.
Treating patients with movement difficulties and pain due to neurological damage can often require surgery, injections of botolinumtoxin (neurotoxin) or strong medications.
“These treatments mean high costs and side effects, while our clothes are simple and safe to use,” Lundqvist says. “You can reduce the number of hospital visits because the therapy can be performed at home. And when the mobility increases, there is less need for walkers or wheelchairs.”
Mollii is an approved CE marked medical device, but independent clinical tests have yet been performed. But the company behind the treatment, Inerventions, has launched a scientific study of the clinical effectiveness of the garment, in partnership with Sweden’s Rehab Medical clinics. Lundqvist says the results should come next year.
Today, Mollii is available through the Swedish health care system as a personal tool prescribed by physical or occupational therapists. And the garment can also be purchased directly from Inerventions.
The price is about EUR 5,600 for two years guaranteed spasticity treatment. If the suit during that time becomes too small, the patient can switch to a new, tested garment at no additional cost.
In Denmark, the garment is already subsidized with municipal funds for treatment of nerve damage, based on recommendations from a physiotherapist.
Inerventions’ goal is to establish Mollii in Europe, the U.S. and Japan. The garment can in the future be used to help patients with chronic pain and people with Restless Legs Syndrome (RLS).

Images at link.