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Spinal Cord Stem Cell Transplantation for Spinal Cord Injury

Spinal Cord Stem Cell Transplantation for Spinal Cord Injury

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By A.Willison
Reviewed by B.Davies

​Humans require many different repair and renewal strategies. At the earliest point in life, we need these pathways to grow and develop but in later life, we use these pathways to recover from disease and injury. For this, our bodies activate a unique type of cell known as a stem cell. Stem cells are a special form of cell, as they can make any cell type in the body, and so can provide building blocks for our organs and tissues.  

Over the past 20 years, researchers have been trying to harness the power of stem cells to guide damaged nerves in spinal cord injury (SCI) towards repair, or to grow new nerve cells altogether. By doing so, it is hoped that the damage can be undone, and a more effective treatment can be offered to those living with SCI. 

Recently, a Californian group led by Dr.Joseph Ciacci, has released an exciting clinical study where, for the first time in humans, four patients had a special preparation of foetal spinal cord stem cells (called Neuralstem) transplanted directly into their spinal cord at the site of injury. After following the patients’ recovery for over two years, they discovered that 3 of the 4 patients had made some improvements. Two patients recovered sensory and motor function, with a third patient showing an improvement in motor activity.  Whilst these changes were measured, it is noted that this did not lead to a change in the patient’s quality of life.  Importantly, the researchers also found no concerns about the safety or side effect profile of stem cell transplant. 

Strategies to repair the spinal cord are sorely needed, and whilst these findings must be treated with significant caution (as there was no group of patients to compare to and the improvements did not reach statistical significance), they are promising as typically for this group of patients, so far down the line after injury, no improvement would be expected. 


Much more work is required before this could lead to real world treatments, and we look forward to follow this story. 

References

  1. Curtis, E et al. 2018 A First-in-Human, Phase I Study of Neural Stem Cell Transplantation for Chronic Spinal Cord Injury Cell Stem Cell  Jun 1;22(6):941-950.e6. doi: 10.1016/j.stem.2018.05.014

The Power of the Word

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​By Iwan Sadler

​Words can be powerful when spoken or in thought. Words are used on so many different levels from the expression of your thoughts to the decision you will make within the moment.Peace is delivered with words but also wars are started by the spoken or written word.

We choose our life choices on words. The average person can speak between 125 and 150 words a minute, but the rate of “expanded inner speech! (word-for-word) is slightly faster than verbal speech. That puts into perspective how many words enter our train of thought on a daily basis. Some decisions can sometimes be made in seconds – other decisions take a lot longer. One thing is for certain: they are all decided with words. 

With the technological development of the internet and mobile phones, words are used more now than ever. The average person uses their mobile phone for approximately four hours per day and around 18.7 billion text messages are sent around the world on a daily basis. And we can’t forget the amount of words we use on our social media platforms. I think you’ll agree that’s a great quantity of words.

This just shows how important words are for our social integration and how powerful words can be. They say that concurring thoughts will eventually become your actions so should we be careful at what we think? Many people think that words, once spoken, cannot be taken back and the action of those words, even if they were delivered within seconds, will last and echo for a lot longer. 
So should we be more careful with what we choose to say? Do words really cut deeper than a knife and leave longer lasting invisible scars? Could our words to a situation decide the overall reactive decision to a situation? Can our words totally change a decision within a scenario? The answer is “Yes!” Our action will always lead to a reaction and the outcome will always depend on our words.

“Where are you going with all this?” you may ask and “What has this got to do with living with a chronic condition?” Could the words we think and use every day help us deal with our condition? Remember that the actual words you say matter, not just the thoughts you convey. Try to use more positive words on a daily basis even if you are unable to replace negative words with positive ones, try replacing them with more accurate neutral ones. Instead of, “This chair is horrible”, try“This chair is not for me.”

Try not to use absolutes, especially in relation to your goals, where falling short of your expectations can be particularly depressing. These words and phrases include: “always”, “never”, “nothing” – the list goes on. Replace them with nuance. Instead of, “I can walk that far”, try “Sometimes I can’t walk that far”.

So the key is to think and speak in a more positive manner. Positive thinking often starts with self-talk. Self-talk is the endless stream of unspoken thoughts that run through your head. These automatic thoughts can be positive or negative. Some of your self-talk comes from logic and reason. Other self-talk may arise from misconceptions that you create because of lack of information.

Positive thinking doesn’t mean that you keep your head in the sand and ignore life’s less pleasant situations. Positive thinking just means that you approach unpleasantness in a more positive and productive way. You think the best is going to happen, not the worst.

The Health Benefits of Positive Thinking
Researchers continue to explore the effects of positive thinking and optimism on health. Health benefits that positive thinking may provide include:

  • Increased life span
  • Lower rates of depression
  • Lower levels of distress
  • Greater resistance to the common cold
  • Better psychological and physical well-being
  • Better cardiovascular health and reduced risk of death from cardiovascular disease
  • Better coping skills during hardships and times of stress

You can learn to turn negative thinking into positive thinking. The process is simple, but it does take time and practice – you’re creating a new habit, after all.

If you are looking for another way to relieve discomfort that doesn’t involve drugs, some age-old techniques – including meditation and yoga as well as newer variations, may help reduce your need for pain medication.
Research suggests that because pain involves both the mind and the body, mind-body therapies may have the capacity to alleviate pain by changing the way you perceive it. How you feel pain is influenced by your genetic makeup, emotions, personality, and lifestyle. It’s also influenced by past experience. If you’ve been in pain for a while, your brain may have rewired itself to perceive pain signals even after the signals aren’t being sent any more. Stress and pain are tightly connected and can have a strong influence on each other. Therefore, if positive thinking is able to counter some of the effects of chronic stress, it could also help lower pain levels.


Practising  Positive Thinking Every Day
If you tend to have a negative outlook, don’t expect to become an optimist overnight. But with practice, eventually your self-talk will contain less self-criticism and more self-acceptance. You may also become less critical of the world around you.

When your state of mind is generally optimistic, you’re better able to handle everyday stress in a more constructive way. That ability may contribute to the widely observed health benefits of positive thinking.

​Final Thought
Being careful with our self talk is essential for our own. wellbeing. And we can also take care to avoid ill-considered words that could damage the wellbeing of others. 
Our minds too often seem to be programmed to keep recalling and dwelling on negative comments which drown out or dismiss any positive feedback we have received. 

The tongue is the strongest muscle in the human body so be careful on how you use it may it be online by txt or word of mouth because “words can only be forgiven not forgotten”.

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Myelopathy Research Struggling To Gain Attention

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By Timothy Boerger
Reviewed by B.Davies

Reason for the study
The number of times a paper is cited is a common metric of how meaningful that paper is to the scientific community. Generally, papers that are highly cited have a profound impact on their field. If scientists look at the trends of which papers are most cited, it can give us an idea of what topics within a scientific discipline are experiencing the most interest over time.

Methods
The prominent journals publishing research related to the spine were first identified from a database of journals. This list of journals including: Spine, Journal of Spinal Disorders, European Spine Journal, Journal of Spinal Cord Medicine, Spinal Cord, Spine Journal, Journal of Spinal Disorders & Techniques, and Journal of Neurosurgery: Spine were searched using the database Web of Science which provides all articles ever published from the selected journals. Articles were then sorted by most citations and the top 100 cited articles were analysed. Articles were then sorted by topic including, 

  1. Biomechanics 
  2. Cervical myelopathy/Cervical fusion 
  3. Degenerative disc disease, deformity 
  4. Iliac bone graft morbidity 
  5. Low back pain 
  6. Lumbar spinal stenosis/Lumbar fusion 
  7. Neck pain 
  8. Osteoporotic compression fractures 
  9. Psychosocial aspects of neck and low back pain 
  10. Tesearch methodology 
  11. Spinal fusion/implantants and rhBMP-2
  12. Spinal metasteses (cancer)
  13. Thoracic fusion 
  14. Trauma/spinal cord injury.

Results
By far the most articles were published in the journal Spine (84/100 articles). This suggests that the journal is publishing a substantial body of the spine research which is both impactful and broadly of-interest to clinicians and researchers of spinal conditions. Ranked according to most articles by topic, low back pain was 1st and had over 2x as many articles represented as any other topic area (22/100 articles). Ranked according to most articles by topic, Cervical myelopathy/Cervical fusion was tied-9th with 3/100 articles. Of these 3, all were on operative techniques for different aspects of cervical myelopathy. The most recent of these 3 articles was published in 2001 (the other 2 were published in 1983 and 1981). Neck pain was 12th.

Why is this important?
The number of times an article was cited is often an indicator of how popular a topic is. This suggests that cervical myelopathy, despite its prevalence and impact upon a person, has received relatively little impactful research. Impactful is an important caveat here; a terrible study, or one that only marginally advances the field, will probably not receive a lot of citations in the future. This means that researchers that look at myelopathy need to produce impactful research that helps us understand mechanisms of the disease, its impact, etc. that may help drive more interest and produce more highly impactful work and better treatments.

It isn’t all doom and gloom, however. On Aug 1, 2018 I searched pubmed (another database of research articles) for all research containing the keywords

  1. cervical myelopathy 
  2. cervical Spondylotic myelopathy 
  3. degenerative cervical myelopathy 
  4. cervical laminectomy 
  5. anterior discectomy and fusion 
  6. cervical disc replacement 
  7. cervical corpectomy
  8. posterior cervical discectomy


and got 24,107 results. Similarly if you search “low back pain, one would get 34,002 results in the same database. This suggests that there is a decent amount of research compared to low back pain, but not nearly in the ball park as other disabling conditions such as multiple sclerosis (~80,000 articles). This suggests that more research is needed in all facets of the disease, but this research also needs to be well designed, rigorous, and impactful. It also means that more publicity is needed for this disease to generate more interest in the scientific community.

References

  1. Badhiwala JH et al., Highly cited works in spinal disorders: the top 100 most cited papers published in spine journals. Spine. Epub ahead of print Jun 8, 2018

Making new brain cells: how mice could help astronauts and DCM patients

By M Stewart
Editor: B Davies

It’s a commonly held belief that you can’t grow new brain cells as adult; you’re born with one hundred billion neurons and that’s as many as you’re getting. However, this isn’t quite the case. While new neurons don’t form in most parts of the human central nervous system (the brain and spinal cord), there are two special areas where new neurons do indeed arise after birth. These areas are found in specific parts of the brain with rather complicated names: the subgranular zone of the dentate gyrus  and the subventricular zone of the lateral ventricle. These two areas (which we call the ‘SGZ’ and ‘SVZ’ for short) contain what we call ‘neural stem cells’ (NSCs), which are able to produce new neurons throughout adult life. This production of new neurons from stem cells is called ‘neurogenesis’. 

Figure 1: Neurogenesis in the rodent (A) and human (B) brains. The final destinations of newly born neurons are shown in green. In both man and rodent one site is the dentate gyrus (DG). Neurons from the subventricular zone of the lateral ventricle (LV) end up in the olfactory bulb (OB) in rodents and in a part of the brain called the striatum in man. From Ernst et al 20153.

Interestingly, there’s a link between neural stem cell activity and exercise. Increased levels of physical activity have been shown to increase neurogenesis, and even restore it in mice who have stopped producing new neurons due to genetic manipulation1. Importantly, this increased neurogenesis has been associated with increased learning ability2. While we know quite a lot about what happens to neural stem cells when we move more, we don’t know much about what happens to neurogenesis when we move less. This gap in our knowledge actually rather important when we consider that prolonged reductions in movement are increasingly common. Lack of muscle activity occurs inn prolonged bed rest or neurological diseases which affect motor function, like spinal cord injury, multiple sclerosis or potentially DCM. Alternatively, effects equivalent to reduced movement can occur in prolonged stays in space, where there the reduced gravity means that muscles aren’t placed under load. 

As patients survive longer with neurological diseases and as we expect longer stays in space, it becomes more and more important to understand any links between immobility and neurogenesis for two reasons. Firstly, changes to neurogenesis could affect brain health – it may be that changes to neural stem cells following reduced mobility feed back into disease like MS or DCM and actually become part of the cause. Adult neurogenesis is greatly decreased in Huntington’s disease patients when compared to healthy people, suggesting that there could be a link between reduced neurogenesis may play a role in the disease3. Secondly, exploring the link may help us understand the effects of exercise on the brain. Reduced movement has been shown to impair memory function and learning4 and to change the chemical environment of the brain5. We may also be able to better understand the link between exercise and prevention of neurodegenerative conditions like Alzheimer’s disease, which is associated with degeneration in neurogenic areas6.

For all the above reasons, a team from Italy lead by Rafaella Adami recently set out to explore whether reduced movement lead to changes in neural stem cells7.
The study was done in mice. While mice do have some notable differences to humans in terms of the neural stem cells (see below), these experiments require the dissection of large amounts of brain tissue and immediately after death and so are practically impossible to do in humans. 

PictureFigure 2: Diagram of the HU mouse model. From Barbosa et al 20118

How was this study done?
The researchers wanted to recreate the conditions seen in situations (e.g. neurological diseases) where people can’t move very much. In these situations limbs are ‘unloaded’ – people aren’t using their arms or legs to move their weight around. in something called the ‘hindlimb unloading model’8 (HU) mouse model. Mice are suspended by their tales from the ceiling of a cage, taking the load off their hind legs, but leaving them free to walk on their front legs. Thus the hind legs don’t bear the mouse’s weight and are ‘unloaded’ (see figure 2). Adami et al put a group of mice in this position for 14 days, over which time their back leg muscles shrank significantly, as they would if they were unable to move them due to neurological disease (or if they were in space and carrying no weight!). After 14 days the mice were killed and their brains where dissected to examine the neural stem cells in the SVZ. Brains from mice which had been allowed to run around their cages freely where used for comparison (control). 

It’s important to stress that the mice were well looked after during the experiment. They always had access to as much food and water as the wanted and were visited by a vet 3 times during the 14 days of suspension. The showed the same key mouse behaviours as the free (control) mice and showed no increased levels of stress hormones. Taken together, all these factors strongly suggest that the mice suffered “little” stress during the experiment.

What were the results of the study?
Firstly the researchers looked at the number of proliferating (dviding/reproducing) cells found in the SVZ. In this case, proliferating cells were the stem cells that were dividing to make neurons, so more proliferation suggests more neurogenesis. Adami et al found that there were 70% fewer proliferating cells in the HU mice compared to controls – so neurogenesis was reduced. 

The team then wondered if this reduced proliferation meant that the stem cells themselves had changed in some way. To explore this possibility, they then took NSCs out of the HU and control mouse brains and grew them in a dish, to form a ball of stem cells and neurons. They saw that stem cells from HU mice divded more slowly than in controls, taking 7 days to double in number (the controls only took 2 days). They also checked that this slower rate of growth wasn’t due to cells dying.

Overall, these findings led the team to their first key result: reducing movement reduces the proliferative capacity of neural stem cells. 
Adami et al then wondered what caused this reduced proliferation. They discovered that it was because the more of the HU mouse stem cells appeared to have become stuck in the ‘resting state’ when compared to the control mouse stem cells. 69%  of HU stem cells were found to be in a resting state, compared to 57% of controls. Far more of the control cells were in a very active, dividing state (21% vs 13% of HU mice).
The researchers then looked at whether the neural stem cells were able to form mature neurons. They found that 6.8% of control stem cells could form mature neurons, whereas only 0.5% of HU stem cells could. 

This lead the team to their second key result: reducing movement reduces the maturation capabilities of neural stem cells. 
Next, Adami  et al explored whether the metabolism (energy production) of neural stem cells in HU mice had changed. Most neural stem cells produce energy by a process called glycolysis, which by produces a byproduct known as lactate. HU stem cells produced significantly less lactate than controls cells, suggesting that reduced movement gives neural stem cells an abnormal metabolism. 

Finally, to try and understand what could be underlying these changes, the researchers looked at gene expression in the neural stem cells. They found that expression of 2 genes were significantly different between HU and control samples. A gene known as CDKrap1 was 3.5x lower in HU stem cells than in controls, while a gene known as cdk6 was 2.3x high in HU stem cells. Overall, it appears that reduced movement changes the genes expressed in neural stem cells. Adami et al haven’t commented on what these different levels of cdkrap5 might mean, but they think that the higher levels of cdk6, which helps keep cells in the resting state rather than dividing, could explain the reduced neurogenesis seen in HU mice.

What do these results mean for DCM?
Right now, not a great deal. This work is still very much ‘blue sky research’ intended to see if the neural stem cells are worth further study for neurological disease (or space travel!). While its fascinating to see that that restricting movement leads to change in neural stem, we have to be cautious in how far we extrapolate the results to humans. Firstly, while mice and humans may be similar, they aren’t the same (newly born neurons rom the SVZ actually end up in a totally different places in mice and people). Secondly, while DCM can involve reduction in movement if nerve damage progresses to an extreme stage or pain becomes debilitating, it’s not quite as clear cut as in this mouse model. Therefore it’s hard to say if neural stem cells would undergo the same changes in DCM patients as they do here. Thirdly, it’s difficult to understand the implications of the results when we don’t fully understand how/if reduced neurogenesis contributes to neurological diseases. Furthermore, the consequences of reduced neurogenesis are likely to vary across conditions – changes to neurogenesis might be completely in DCM than they are for something like Huntington’s. 
The next step will be to explore the nature of neural stem cells in other mouse models of reduced movement, such as multiple sclerosis, spinal cord injury and DCM to see if neural stem cells undergo similar reductions in neurogenesis. Then we’ll need to determine how/if reduced neurogenesis might contribute to the problems we see in these conditions. If such a contribution was confirmed, this could be a breakthrough in our understanding of how DCM develops. We might even then be able to developing new treatments which target the neural stem cells themselves. However, there are many steps we must take before we reach that stage – for now we’ll have to move slowly. Watch this space for more!


1.    Farioli-Vecchioli, S. et al. Running Rescues Defective Adult Neurogenesis by Shortening the Length of the Cell Cycle of Neural Stem and Progenitor Cells. Stem Cells 32, 1968–1982 (2014).
2.    van Praag, H., Shubert, T., Zhao, C. & Gage, F. H. Exercise Enhances Learning and Hippocampal Neurogenesis in Aged Mice. J. Neurosci. 25, 8680–8685 (2005).
3.    Ernst, A. & Frisén, J. Adult Neurogenesis in Humans- Common and Unique Traits in Mammals. PLOS Biol. 13, e1002045 (2015).
4.    Wang, T. et al. iTRAQ-based proteomics analysis of hippocampus in spatial memory deficiency rats induced by simulated microgravity. J. Proteomics 160, 64–73 (2017).
5.    Dupont, E., Canu, M.-H., Stevens, L. & Falempin, M. Effects of a 14-day period of hindpaw sensory restriction on mRNA and protein levels of NGF and BDNF in the hindpaw primary somatosensory cortex. Brain Res. Mol. Brain Res. 133, 78–86 (2005).
6.    Guure, C. B., Ibrahim, N. A., Adam, M. B. & Said, S. M. Impact of Physical Activity on Cognitive Decline, Dementia, and Its Subtypes: Meta-Analysis of Prospective Studies. Biomed Res. Int. 2017, 1–13 (2017).
7.    Adami, R. et al. Reduction of Movement in Neurological Diseases: Effects on Neural Stem Cells Characteristics. Front. Neurosci. 12, 336 (2018).
8.    Barbosa, A. A. et al. Bone mineral density of rat femurs after hindlimb unloading and different physical rehabilitation programs. Rev. Ceres 58, 407–412 (2011).


My Island

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BY Alison Murphy  MY…Hell…opathy Laughing & living with Cervical Myelopathy

Yesterday, my husband dropped me off at the swimming baths.  The large float around my waist and my cycling style of swimming does raise a smile or two. Some call me a ninja turtle, some the barnacle woman.  Today my predicament was in the changing room.  With my combination lock.  I tried it, retried it, again and again to no avail.  It wasn’t the wrong combination; it’s my date of birth but the lock is old and sometimes you have to press it together for it to open.  I could see my issue was attracting the attention of others. So in my swimming costume, dripping, I went to reception.  A female employee, with bolt cutters came to my rescue.  She struggled a little until suddenly the lock exploded apart.I opened the locker.  Opps.  Someone else’s clothes.  I used the ‘f’ word; it was called for.The leisure centre girl was laughing. The audience of women changing was lapping it up.  I said this has probably happened to other people.  No, she said.  What an idiot.

​My locker was only three doors away and I didn’t even think to try it.  I was resolutely sure that the locker was mine.  I felt so sorry for whoever’s locker it was.  They came to the leisure centre to work out and relax.  I had to lock their locker with my lock.  I left an apologetic note on their door telling them the combination was at reception.  Then I went for a cappuccino.  With myelopathy you have to let these things wash over you.

​I’ve been a little Norman Bates lately; stable one day, struggling with my myelopathy persona the next but I’m quite proud of myself.  I’ve reached out to people to try to reconnect and everyone’s been so generous with their time and considerate of my condition. I’ve been going to events and sometimes only staying an hour; but enjoying that hour.I went to a lovely patisserie for coffee and cake this week but told Diane I could only stay an hour because I can’t stand independently, or straighten, if I sit over the hour. Also I’m learning how to be a bit precious. My husband calls me the princess and the pea because everything has to be just so.  If a chair is too soft my back spasms, if my shoe laces are too tight I can’t put shoes on, if my teacup is too full I can’t lift it, if there is spice in my food I get IBS.  I went from being totally laid back, able to eat street food cooked by greasy haired, uncompliant to hygiene standards, cooks to being very needy.  I don’t beat myself up about it.  I’m not elderly or frail or sick but titanium is holding my neck together and if I’m not careful my cervical spine might topple like Jenga bricks again.  So, when I’m chatting I need my friend opposite me, not beside.  I can get in a car, but I can’t get out without help.  I need to be front of the loo queue because I can’t hold it. If we can’t be fussy now, when can we?


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When the kids were little I would make up silly songs randomly about their activities and personalities.  I’d wake them up with a song, tuck them in with a song.  For a couple of years myelopathy stole my voice.  It truly is a challenging condition.  I wake up and feel how I image the wolf did in Red Riding Hood when his stomach was filled with stone.  My body is so uncomfortably heavy, my bones hurt, my head is constantly under a vice like pressure…and that’s at the start of the day!  Understanding cervical myelopathy has been an uphill struggle, health professionals are not up to speed with a condition whose numbers are constantly rising.   When my daughter was little she was given many Barbies and the first thing she’d do is cut Barbie’s hair off. Grace, I’d say, it won’t grow back, once it’s cut, it’s cut and that’s like the spinal cord, damage is unrepairable – for now anyway.  It’s through contact with fellow suffers at www.facebook.com/groups/myelopathy.support that has me bursting into song again.  Knowing that I haven’t got some one-off, obscure condition, that I’m not alone, is a huge deal.

My youngest daughter was eighteen yesterday.  When I think of Caitlan it’s like my heart bursts like a popping champagne bottle.  She was ten when I was first admitted to hospital with what doctors thought was a stroke. We’re throwing her a party.  If I thought too much about the organisation I’d feel overwhelmed.  I’ve called it a casual gathering, that way expectations aren’t so high.  I think if you have alcohol and food a party will run itself.  My brother and his family are over from Kilkenny, Caitlan’s godparents from Dublin, I can’t wait.  Having something to look forward to is paramount.  I look forward to coffee with my husband, I love going to M&S Food Hall, I have book club, I love Grace coming home for the weekend.  My four children are the painkiller that get my weak body out of bed.  They are the smile on my face.  They understand my condition better than neurologists, they live with my highs and lows and they pick me up.

I am happy.   It’s a glorious feeling.  Once I get going I feel my life is full of possibility even though by four I will be totally slayed with pain and tiredness, my limbs will be unresponsive, and I will sway around the house, everything falling from my grip…I’ll end up in bed for a few hours but at nine I will be enjoying Love Island with my family. If I think of 2018 so far I’ve been part of a training video to help doctors diagnose myelopathy earlier, I’ve been skyped (never skyped before) by Dr Nidhi who is gathering info to support early diagnosis.  I’ve enjoyed two book club gatherings.  Met Sharon for a pub lunch.  Gone for innumerable coffees and cake and have the calories to prove it.

Caitlan recently returned from a geography trip to Iceland.  Putting on her crampons, about to step foot on a glacier she thought of me.  My mum will never do this, she’ll never see this powerful landscape with winds that take your breath away.   It’s true.  But it’s ok.  I’ve come a long way since my dramatic arrival at A&E.  I’m walking.  I’m sleeping.  I’m managing my pain.  I’m with my family.  I think of my life like Bear Grylls’ The Island.  Myelopathy is my island.  I’m not a giver upper and I’ve learnt to enjoy simple things.
Right now I’m sitting by the window, the sun is shining, a squirrel has just run the gauntlet across my garden fence while my two dogs are going bonkers.  Spanish rap is playing. I’m glad to be alive; the alternative is an eternity I’d like to avoid.  I’ve come to not expect too much of myself.  Myelopathy is the long game.

You can check out Alison’s blog My Hell opathy here 


Neck Muscles and CSM/DCM

By Timothy Boerger
Reviewed by B.Davies

Neck Muscles and CSM– An Update Part 1 of 2

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​This will be the first of a 2 part mini-series on the properties of muscles in the neck and how they impacts outcomes of surgery. We previously looked at this following an early piece of research from North America.  This series will serve as an update on this research. 


Why was this study conducted?

As outlined previously, the amount of fat found within muscles has been linked to the type of symptoms experienced by patients; including the amount of neck pain and walking ability. This new study was done on a separate cohort of patients than the previous study and included measures of neck strength and other quality of life scales not assessed previously which addresses some weaknesses of the previous study.

How was the study conducted?
This study used MRI imaging to measure the size and the amount of fat in muscles in the neck. Neck strength was measured by clinicians using a hand held force sensor. Several questionnaires were performed to assess function, pain, and quality of life. Importantly, this study used what is called a “cross-sectional’ design meaning it only looks at 1 time point. 

What was discovered?
Larger muscles and larger amounts of lean muscle (i.e. muscle without fat) in the neck were associated with increased strength. (We already knew this in general, but it is good to ensure there isn’t something different about patients with cervical myelopathy). More fat in muscles of the neck was associated with more disability measured by the mJOA. Importantly, neither strength, muscle size, or muscle fat were associated with pain, duration of symptoms, neck disability index, or quality of life in this study.

Why is this important?
Between the previous study linked above and this study, it appears that muscle fat may be a biomarker of disability and function in patients with myelopathy.  Currently there are no biomarkers for myelopathy, which makes it difficult to assess how severe it is or give an idea of how things will develop.  More research will be needed to investigate the usefulness of muscle fat as a biomarker, but given that it can be quantified based on existing widely avaliable imaging techniques, it could enter routine clinical practice quickly.
 

Why could muscle fat relate to the severity of myelopathy?
One reason this is being investigated is that fat infiltrates muscle as a response to nerve injury and disuse. For example, if a nerve is injured the nerve doesn’t tell the muscle to contract as much and it allows more fat to become deposited within the muscle itself. 
    

References

  1. Fortin M et al. Relationship Between Cervical Muscle Morphology Evaluated By MRI, Cervical Muscle Strength And Functional Outcomes In Patients With

Degenerative Cervical Myelopathy. Musculoskeletal Science and Practice. 38; epub 2018: 1-7 

  1. Fortin M, et al. Association Between Paraspinal Muscle Morphology, Clinical Symptoms and Functional Status in Patients With Degenerative Cervical Myelopathy. Spine (PhilaPa 1976). 2016 May 23

More to Myelopathy than meets the eye

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By O.Mowforth
Edited by B.Davies

We don’t really know what symptoms a “typical” patient with myelopathy has. 
In fact, the huge number of often quite subtle and non-specific symptoms is probably one of the main reasons why early diagnosis is so challenging (Davies et al., 2018).
 
When medical students prepare for exams they tend to learn stereotypical descriptions of conditions. For myelopathy, this might be a patient with walking problems and clumsy hands.

However, increasingly symptoms that one might never consider could be linked with myelopathy are emerging from the shadows.

Depressed or anxious mood is one such symptom (Stoffman et al., 2005). 
In recent years we have realised that myelopathy patients suffer from high levels of depressed or anxious mood and that this often improves after spinal surgery. But we have had little understanding of why this is the case.

A recent study from Japan has provided a little more insight (Sawada et al., 2018). The Japanese team studied the activity levels of various sites in the brain in myelopathy patients before and after surgery. They also studied individuals without myelopathy as a control group for comparison.
To do this, the team asked participants to do a simple finger-tapping exercise whilst they observed activity levels in the brain using functional magnetic resonance imaging.

The team found that before surgery individuals in the myelopathy group had a significantly higher activation in an area of the brain called the supplementary motor area compared to individuals in the group without myelopathy.
Next the team found that activation of brain areas, including the anterior cingulate cortex, the supplementary motor area and the thalamus significantly correlated with depression. This meant that the greater a patient’s depression, the greater the activation they had in these brain areas.  
Finally, the team found that both depression and activity in the anterior cingulate cortex and supplementary motor area decreased following surgery for myelopathy. 
Interesting!

The team argue that up to now surgeons have focussed on the “typical” symptoms such as the clumsy hands and walking problems when deciding whether to operate. They believe that their work may lead to future surgical decisions taking more account of the psychological symptoms too!

Davies, B.M., Mowforth, O.D., Smith, E.K., and Kotter, M.R. (2018). Degenerative cervical myelopathy. BMJ 360, k186.
Sawada, M., Nakae, T., Munemitsu, T., and Hojo, M. (2018). Cortical Reorganizations for Recovery from Depressive State After Spinal Decompression Surgery. World Neurosurg. 112, e632–e639.
Stoffman, M.R., Roberts, M.S., and King, J.T. (2005). Cervical spondylotic myelopathy, depression, and anxiety: a cohort analysis of 89 patients. Neurosurgery 57, 307–313; discussion 307-313.


Community Champion Frank Dutton shares his top fundraising tips

As a Myelopathy.org Community Champion, I had the honour of holding the charity’s first fundraiser at my local football club.

PictureCommunity Champion Frank Dutton

Myelopathy.org and Myelopathy Support on Facebook have been a great help for both me and my wife since my diagnosis in 2016. Since then, life has been difficult to say the least. Cervical myelopathy, and the accidents it has caused, have led to me going under the knife for no less than six major surgeries. These have significantly affected my body and its ability to cope with everyday life.

I created a ‘lucky numbers’ board featuring 1-100. I then made a list of those numbers with spaces next to them for people to write down their names and telephone numbers. It cost £1 per number and I decided on a winning pay-out of £25 which, if all the numbers had been taken, would deliver a tidy profit of £75 for Myelopathy.org. 

I set my table up in the club room. I took along some laminated photos of people’s CT scans, including my own, as visual aids. I also made copies of one of the charity’s media releases about the condition and the need for early diagnosis, and the basic facts about myelopathy. These are part of the Myelopathy.org fundraising pack. 

It was very interesting to see how people reacted to the photographs and then responded to the information in the leaflets and that I was able to supply about myelopathy. 

The fundraising experience was a positive one and the fact that I was able to raise £71.10 (no idea where the 10p came from) was a bonus. I am now really looking forward to taking part in the next fundraising event. So, if you have any ideas or want to hold a fundraiser yourself, please let me or one of the Myelopathy.org team know.

My top five tips for fundraising.
1) Plan where you want to hold your fundraiser and contact relevant authority/fête organiser/owner etc for permission

2) Share, share, share. Use social media, such as Facebook, WhatsApp, Instagram etc, to gain maximum promotion and coverage for your fundraising activity.

3) Make it personal. Tell your own story so that people can understand more about your experiences and your reasons for fundraising. Sometimes that personal touch/story can elicit donations.

4) Remember your inspiration. There’s a reason why you are supporting this cause. Hold on to your inspiration and bring all that enthusiasm to your fundraising activities.

5) Have fun. If you are not enjoying yourself, you will give off all the wrong vibes. So, smile and perhaps rope in a friend or two to help so that you can jolly each other along.


    If you would like to organise your own fundraising even then please leave your details below

Neck Muscles and CSM– An Update Part 2 of 2

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By Timothy Boerger
Reviewed by B.Davies

Neck Muscles and CSM– An Update Part 2 of 2
This second of a 2-part mini-series on the properties of muscles in the neck and how they impact outcomes of surgery. We previously looked at this following an early piece of research from North America.  This series will serve as an update on this research.

Why was this study conducted?
For a short recap of the previous 2 blogs related to this: how much fat there is within muscles has been related to symptoms of myelopathy. Additionally, cervical lordosis, or, the curve of the neck, is believed to be related to outcomes following laminoplasty.1 

How was the study conducted?
This study performed a pre-operative MRI at which they performed measurements of the neck muscles. They then tracked the participants for 12 months post cervical laminoplasty to assess the curvature of the neck with x-ray.

What was discovered?
The main finding was that muscle size at multiple vertebral levels in the neck is related to loss of curve following surgery. The smaller the neck muscle size, the greater loss of neck curve.

Why is this important?
This is further evidence suggesting the muscles in your neck are important in myelopathy.  It should be noted that this study only looked at patients who underwent a laminoplasty, one of many different types of surgical procedure for myelopathy (i.e. it is unclear whether this finding would be applicable to other types of surgery such as ACDF).
​ 

Whilst this link is again being drawn, it remains to be seen whether or not treatments to help neck musculature could make a difference to patients.  The authors in this study suggest it could better advise on the type of surgery that is to be performed.  Drilling down to these questions will be an important next step for this line of research. 

Have you had any therapy to strengthen your neck pre- or post- surgery? Did it help?
    
Reference
Lee BJ et al. Importance of the Preoperative Cross-Sectional Area of the Semispinalis Cervicis as a Risk Factor for Loss of Lordosis after Laminoplasty in Patients with Cervical Spondylotic Myelopathy. Euro Spine J. epub 2018: 1-10


Heart Break for Myelopathy

Risk of acute coronary syndrome in patients with cervical spondylosis 
​J.Hamilton

What were the aims of the study?

Various studies in the past have described cervical spondylosis (CS), the degenerative changes in the cervical bones and ligaments contributing to degenerative cervical myelopathy, as associated with increased sympathetic nervous tone[1][2].

The sympathetic nervous system plays a role in controlling blood pressure, heart rate and various other aspects of our cardiovascular health.  But part of its control structure also lies in close proximity to the cervical spine. 

Increased sympathetic activity is known to contribute to increased atherosclerosis and cardiovascular events such as stroke, and myocardial infarction (heart attack)[3]

​The authors noted that no research had been done to link the above statements, if CS does cause increased sympathetic activity, does this logically follow that CS causes an increased incidence of cardiovascular events?
 
With this in mind, the aim of the study was to determine if cervical spondylosis increased the risk of cardiovascular health issues, specifically acute coronary syndrome (ACS), which in common terms is a heart attack.

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The sympathetic nervous system is involved in controlling many of your bodies organ systems. Signals originate from ‘ganlgion’ that lie adjacent to the spine. The ganlgion in the cervical spine are involved in control of the cardiovascular system

How was the study performed?

The authors used a national insurance claims dataset of 22 million people in Taiwan and identified 27,947 patients with CS, they then matched this with a similar number of non-CS patients of a similar age and gender distribution, as well as matching numbers of patients with other health problems such as hypertension, diabetes, asthma and stroke. This was to allow them to compare the incidence of ACS between the groups without other diseases invalidating the comparison. 

All the patients were followed up until they had a diagnosis of ACS, died, or the end of the research period occurred at the end of 2011. After this, the number of ACS events in each group were measured as a rate over the number of “person years”. This being the number of times a diagnosis of ACS was made for every year a patient lived.
 
In this paper, the incidence of ACS was measured as number of ACS/1000-person years. These were then compared between various groups to obtain a ratio, to determine the relative risk of ACS occurring in a person with CS compared to someone without ACS in a similar state of health.


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What were the main findings?

Overall, the study showed that patients with CS were 13% more likely to have an ACS, than patients without CS. This was determined ‘statistically significant’, but in real terms this represents a very small increase from 3.9/1000-person years to 4.27/1000-person years in rates of ACS diagnosis. 

Looking in more detail at the patients with CS, for those with myelopathy the risk was slightly higher, increasing by 20% but interestingly, it seems treatment of CS has an effect in reducing ACS risk:
– 
Patients receiving spinal decompression surgery were less likely to have an ACS (27% reduction)
– Patients receiving rehabilitative therapy were less likely to have an ACS (33% reduction) 

The statistical difference between the form of treatment for CS and reducing ACS risk was not significant.  

​How could cervical spondylosis cause acute coronary syndrome?

This is a good question, and not entirely clear.  The researchers suggested that it may be to do with the sympathetic trunk. The cervical sympathetic trunk consists of collections of nerve cells bodies, called ganglia, aligned along the front of the spine.  The ganglion in the neck are involved in control of the cardiovascular system.  This special group of nerves also connect with the ligaments of the spinal column, such as the posterior longitudinal ligament, and the lining of the spinal cord. Irritation to these structures is thought to cause the sympathetic nervous system to increase its output, for example to fibers in blood vessels around the body, causing them to constrict and causing hypertension, which contributes to a diagnosis of ACS.

What can we take from this study?

This is not the first study to show a relationship between CSM and Cardiovascular health (we have previously described a study specifically looking at high blood pressure), however it is the first to show an increased risk of a heart attack.

There are a number of limitations to this study, and the actually increases in risk are relatively small.  But it adds to the research of CSM and Cardiovascular disease, and once again shows the far reaching impacts of CSM.    

References

Shih-Yi Lin et al. Risk of acute coronary syndrome in patients with cervical spondylosis ​Atherosclerosis 2018

[1]M. Singh, I. Khurana, Z. Kundu, A. Aggarwal, Link of sympathetic activity with cardiovascular risk in patients of cervical spondylosis, Int. J. Clin. Exp. Pathol. 3 (2016) 41e44 
[2]M. Singh, I. Khurana, Z.S. Kundu, A. Aggarwal, Galvanic skin response in pa- tients with cervical spondylosis, IJHSR 6 (2016) 148e152.
[3] N. Marina, A.G. Teschemacher, S. Kasparov, A.V. Gourine, Glia, sympathetic activity and cardiovascular disease, Exp. Physiol. 101 (2016) 565e576,