Preliminary results of our study of successful aging with multiple sclerosis; learning from ‘MS veterans’

People with MS, just like people everywhere, aim to age well; maintaining physical and mental health for as long as possible. We undertook this survey in order to learn as much as we can from older people with MS. They are the people who know about aging with MS from first-hand knowledge and rarely have they been asked their opinions.

To hear from this group, we surveyed older Canadians who were over 55 years of age with MS for 20 or more years. One person told me she was an ‘MS veteran’. We heard from 743 people. (Thank you to you all for contributing to research to help others with MS!).

We have just published the preliminary findings in BMJ Open. The link to the full article is below. We have more papers to follow so I will update as they become available. 

Even though about half of the respondents had major walking problems, they reported that they drank less alcohol, exercised more and smoked less than other Canadians their age. In general, they were more attentive to their health.

Our future papers will provide more information on the effects of other health conditions (like arthritis, heart disease and cancer), differences in aging between men and women, and predictors of exercise.

http://bmjopen.bmj.com/content/4/7/e005718.full.pdf+html

2014 MS Research Webinar

The Multiple Sclerosis Society of Canada is pleased to present the 2014 MS Research Webinar, which will take place on Tuesday June 3 from 6:00 to 8:00 pm Eastern

The webinar will feature a panel of researchers and clinicians who will present the latest in research related to symptom management and quality of life, including such topics as:

The importance of physical activity in MS
Living longer and healthier with MS
Environmental influences and predictors of MS
Physiotherapy and rehabilitation

http://mssociety.ca/researchwebinar/2014/

The inflamed brain

It is surprising to know how frequently inflammation is going on in brain tissue. The aging process itself is associated with dying off of cells, inflammation and mopping up of debris. However there are critical times when inflammation progresses rapidly, inducing both damage and repair (sometimes referred to as a ‘double-edged sword’) especially in stroke and multiple sclerosis. I have been thinking about ‘the inflamed brain’ and if there are strategies that someone could employ to reduce inflammation and enhance repair. I am reading a paper by Wolf-Dieter Heiss at Max Planck Institute for Neurological Research, Cologne, Germany in Annals of NY Academy of Science 2013 about inflammation after stroke. He explains that there are several phases of inflammation after stroke which I will summarize:

STAGE 1: Immediate effects (first few minutes)-when blood flow is reduced to an area, the brain cells, which are high users of oxygen and energy, are no longer able to carry-out their routine activities. The pumps within the cell that keep things in balance, fail. This results in an immediate loss of function of these cells-they do not ‘talk’ to other cells- so the person experiences a sudden loss of normal function (for example, sight, sensation, balance).

STAGE 2: Spreading of damage (first 6 hours or so) – The damaged cells in the core of the damage spill out their contents, including neurotransmitters, which produce waves of chemical/electrical activity in neighbouring cells. The tissue surrounding the core is called the penumbra and now becomes very vulnerable to injury since it is also has reduced blood flow at a time when activity is increasing. So the cells are being driven hard with very little gas in the tank. These cells reach a point when they can no longer function, the pumps fail and they also start to die off.

STAGE 3: Delayed injury (days and weeks)- There are three things happening during this phase, 1. Swelling, 2. More inflammation and 3. An automatic dying off of cells that are connected to the damaged region called ‘apoptosis’. Swelling happens because the chemicals released from dying cells attract inflammatory cells from the body triggering leakage from the small capillaries in the area. This swelling causes pressure because, of course, the brain (and spinal cord) is encased in bone. The inflammatory cells continue to leak in and cause other problems. Finally the cells that were previously connected to the damaged area are no longer receiving information so the body begins to shut them down.

What can be done to tilt the odds in favour of recovery during these phases? Here is what I think..
STAGE 1: This is really about prevention. What can you do so that if you do have a stroke, you have the best possible chance of recovery? Number 1 is to live a healthy lifestyle, reduce your intake of fat and salt, eat colourful foods that contain anti-oxidants which can help to reduce the effects of free radicals that are released when cells are under stress…and finally EXERCISE! Get in 30 minutes of moderate intensity exercise at least 3 times per week and everyday if you can. Walk, climb the stairs at work, cross-country ski, swim, do yoga, cut firewood.. do something that you feel a bit out of breath. Exercise increases blood supply to the brain (see my previous post about angiogenesis).

STAGE 2: if you suspect a stroke get help as soon as you can. There are two main ways to remove a blood clot (if you have one): one using drugs to dissolve the clot and another using a special surgery to insert a device into the blood vessel to grab the clot and either dissolve it or pull it out. Check out the warning signs of stroke here

http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3483937/k.ED98/Stroke__Stroke_Warning_Signs.htm

STAGE 3: Key to enhancing recovery at this stage is excellent early hospital care by controlling body temperature, blood pressure, glucose and providing good nutrition (sometimes just saline in IV or using a feeding tube). The person with the brain injury should also be encouraged to move their limbs and get moving around if at all possible (for example rolling side to side and sitting at the bedside). Family members should be speaking to the person from their most affected side to encourage attention to that side. If the person with the stroke can’t move yet, gently move their limbs. Ask advice from the therapist, doctor or nurse. Be careful not to tug on the person’s affected arm as this can hurt the shoulder very easily. Make sure the affected arm does not droop over the side of the bed. Be aware that swallowing can be slowed so the person should be assessed before allowing them to drink liquids.

I encourage you to review the Canadian Best Practices for Stroke Care-an excellent resource for health professionals, patients and families based on research evidence.

http://www.strokebestpractices.ca/

Rehabilitation is for life

http://vimeo.com/86735159

This video is of Camp No Limits; an outdoor, physical challenge and rehabilitation camp for childhood amputees. It is run by a very close physiotherapy colleague of mine. When I watch it I think of two things:

1. Rehabilitation is for life: If you read back to my old post about ‘Recovery is a marathon not a sprint’, this story of Camp No Limits embodies the important concept that learning and recovery never ends. You have to challenge yourself to try the movements or tasks that seem to be beyond your capability right now-but one step at a time. Set goals for yourself. Find the right resources around you to give you the support you need. I know that before Camp No Limits, there were few opportunities for young amputees to get the coaching they needed to live life to the fullest.

2. Neuroplasticity underlies new learning: Although these children do not have brain injury, they are capitalizing on neuroplasticity. As they practice and learn new skills like rock climbing, riding a bicycle and even riding a mechanical bull, neuroplasticity is at work to make new connections within the brain so that the new skill can be learned.

How to grow more blood vessels in the brain and why you should do it

Think about the blood vessels in your brain like streets in a growing and changing city. The blood vessels are critical to the movement of necessary nutrients to brain cells and the removal of undesirable toxins and waste products. In the city, the thoroughfares (arteries) move large volumes of traffic whereas the small side streets (capillaries) are able to penetrate deep into neighbourhoods.  Arteries and capillaries are the streets of the brain and make sure blood flows to the energy-consuming brain cells in every nook and cranny.

For the brain challenged by trauma, infection, stroke, dementia, Parkinson’s, multiple sclerosis and other disorders, density and quality of blood vessels is critical. Fortunately, the brain has the ability to modify its own blood vessel network just like the city can respond to growth of new suburbs by widening and building new streets. Angiogenesis is the sprouting of new capillaries from preexisting blood vessels while arteriogenesis is the increase in diameter of collateral (neighbouring) vessels in response to blockages in vessels that are the main suppliers of an area of tissue.

Most of what I am discussing here is reviewed exceptionally well by Ergul and group from University of Georgia in the journal Stroke (2012) and  Schmidt and colleagues from Charité University Medicine Berlin, Germany in the journal Cerebrovascular Diseases (2013). So for more detail read those. I will focus on angiogenesis since it is believed to be the primary method of growing new blood vessels in the brain.

So why is angiogenesis important? Angiogenesis increases blood flow to brain tissue which is especially important after a stroke or other injury to the brain. This has three beneficial effects 1. Improving the survival of vulnerable cells in the boundary zone around the damaged area,  2. Removing debris and unwanted chemicals and enzymes from the area and, 3. Creating an environment ripe for growth of new synapses and neurons (neuroplasticity). (Read my previous posts on Neuroplasticity for background)

 Exercise and Physical Therapy-induced Angiogenesis

What we know from animal studies is that exercise before a stroke, builds tolerance to brain ischemia (is-key-me-ya: lack of blood supply to a region of the brain). Animals engaging in regular moderate exercise before a stroke have less damage and better recovery than inactive animals. After a stroke or brain injury, exercise (and physical therapy) stimulates angiogenesis and improves physical and cognitive functioning.

So how much exercise is required to induce angiogenesis? My colleagues and I have just completed a review of studies examining the effects of exercise on angiogenesis after stroke. Of the 6 studies we examined, all were in animal models of stroke (no human studies) and they all used forced wheel or treadmill running. The studies showed that two weeks of daily, moderate to high intensity exercise (walking or running) beginning 1-3 days following stroke resulted in increased markers of angiogenesis. Although this is exciting, it is difficult to translate to the real world setting. First of all, the strokes in animals are very small, sometimes only a few mm. wide, not at all like stroke rehabilitation in humans. Furthermore, it is not practical to ask stroke patients to walk on a treadmill one or two days after stroke. Most are very ill and sometimes not able to sit up, let alone walk on a treadmill. Clearly the timeline in animals after stroke and in humans is very different, but how different we don’t know. A reasonable approach is to make sure aerobic training is included in the rehabilitation process. For the physiotherapist, begin building tolerance to exercise and get the heart rate above baseline gradually increasing intensity each day. Set goals and try to get family members involved. When the patient is able to walk with help, start using your gym equipment (arm ergometer, recumbent bike, etc) adapting them to support the hemiplegic side as necessary.  For the patient and family, try not to spend too much time in bed but if you are there, do your exercises (bridging, lifting your legs and so on). Find out from your therapist how intense you should be training and get help to set up a program. Ask for times you can go to the physio gym to do your aerobic workout.

 

See inside the brain with CLARITY

Last year in 2012, Dr. Karl Desseiroth and colleagues from Stanford University published their technology, called CLARITY, in Nature, the most prestigious scientific journal in the world. CLARITY marks the start of a new chapter in brain imaging. Imagine being able to see through the brain in such a way that you can actually see neurons connect to each other. The YouTube video I have posted below describes their work which is truly exciting. Think about what this means for brain recovery and neuroplasticity research!!

Real-world Challenges of Translating Research Evidence into Clinical Rehabilitation Practice (and vice versa!)

A wise person recently said to me “Sometimes I think the translational issue is one where therapists don’t want to listen, and researchers don’t want to communicate.”
I find myself in an interesting position as both ‘therapist’ and ‘researcher’ and even more convoluted; both ‘basic scientist in neuroscience’ and ‘clinical researcher’. I appreciate the challenges to knowledge translation that he mentions. Research and the application of research to the clinical situation is a complicated issue that sometimes depends on the ‘hat’ you are wearing. When I wear my ‘scientist hat’ I think that clinicians should really seek out evidence-based practice however when I wear my ‘clinician hat’ I understand that in my hectic day I don’t have time to read the hundreds of articles published in my field every 6 months or so.
Researchers don’t seem to want to spend time synthesizing this research for me. Furthermore, in many cases, the studies are performed on specific patients in an ‘ideal’ environment that may or may not be applicable to my patients. The classic example of that is constraint-induced therapy which has been mostly studied in patients with very good hand recovery and no cognitive or memory impairments at all and no other health problems. These patients represent the minority of people I see. The clinician will argue that health researchers should really reach out and study what is really important on the frontlines. So I try not to get offended when wearing my hats. It is true that clinicians, basic scientists, clinical researchers, policy makers are all operating in their own silos and it takes quite a bit of momentum to get cross-talk. I know that the Heart and Stroke Foundation Partnership for Stroke Recovery and other organizations are working on this. I believe lack of communication has got to do with the comfort level that you have when finding yourself in an unfamiliar silo; sometimes you just have to admit that you really don’t understand the methods and applicability of someone else’s area. You just have to be open to learning and collaboration.
In terms of evidence-based practice, only a small fraction of what I do as a clinician has been tested and found effective in people with stroke. It is not that there is evidence to say that my technique does not work; there is just no evidence yet. I must rely on my clinical judgement as well as the advice from experienced and trusted colleagues and the outcomes I see right in front of me among the patients I work with. Researchers tend to study a discrete intervention, like muscle stimulation or treadmill training. Because patients are so different (I have never met two people with stroke who have the exact same recovery profile) I often have to take an eclectic approach derived from research in coaching/training and exercise, research in other conditions and my own creativity and ability to problem solve.True progress will happen when scientists, clinicians and patients collaborate to undertake studies that are grounded in real-world practices and challenges. You don’t have to be an expert in someone else’s area, you just have to be open to communication and sharing.

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