Amyotrophic Lateral Sclerosis (ALS) is a debilitating and fatal neurodegenerative disease affecting upper and lower motor neurons. Though studied for over two decades since the first ALS-associated genetic mutation was discovered, researchers have yet to uncover the pathological processes that lead to progressive degeneration of motor neurons in ALS, or to develop effective treatments. One prominent hypothesis proposes that excitotoxicity caused by increased motor neuron firing plays a role in ALS pathogenesis. While prior studies reported increased action potential firing in early postnatal ALS-model motor neurons in vivo, it remains unknown whether the increased activity stems from increased intrinsic excitability of ALS motor neurons or from increased excitatory drive, and whether these changes are transient or persist into adulthood, when ALS symptoms emerge. In this thesis, I circumvented the difficulties in standard measurement of electrophysiological properties of adult spinal motor neurons in vivo by relying on the visualization of the axon initial segment, a subcellular structure known to undergo compensatory structural changes in response to perturbations in excitatory input. I discovered that cultured motor neurons derived from stem cells of the SOD1G93A mouse model of ALS display shortened axon initial segments and hypoexcitable electrophysiological properties. The shortening of the axon initial segment is compensatory, as ALS motor neurons receive increased numbers of excitatory inputs and manifest increased spontaneous activity. Remarkably, similar shortening of the axon initial segment was detected in early presymptomatic spinal motor neurons in vivo. The shortened axon initial segment persists into the symptomatic stages and is particularly pronounced in motor neurons containing p62 immunoreactive aggregates and neurons exhibiting swollen mitochondria, two signs of stress and neurodegeneration in the disease. Based on these observations I propose that early in the presymptomatic stages of the disease, spinal motor neurons recruit excessive excitatory inputs, resulting in their increased activity that is in part compensated by shortening of the axon initial segment. This state persists and becomes even more pronounced in motor neurons exhibiting biochemical changes preceding neurodegeneration. While these observations support the potential role for excitotoxic stress in spinal ALS motor neurons, I paradoxically observed the opposite phenotype in ALS-vulnerable cranial motor neurons in the brainstem of the SOD1G93A animals, raising the possibility that the cellular stress that drives the neurodegeneration in ALS is motor neuron subtype specific.

Background: Systemic sclerosis (SSc) is an autoimmune disease associated with significant mortality and morbidity. Cardiovascular causes are the single largest contributor to premature death. To date, much of the focus on managing the care of SSc patients has concentrated on traditional risk factors related to fibrotic and microvascular dysfunction. There is, however, evidence of a strong cardiovascular component to the disease and points to macrovascular dysfunction as being a key contributor to the premature mortality associated with SSc. This thesis reports on the conduct of a multi-centre, randomised, placebo-controlled clinical trial (the SSTEP Study). The aim of the study was to assess whether oral Iloprost was more effective than placebo in reducing cardiovascular events and disease progression in SSc. Methods: Two hundred and sixteen patients with systemic sclerosis were recruited, between February 2002 and February 2005, at nine centres in the UK and Ireland. After one month placebo run-in, participants were randomised to either oral Iloprost (50-200mcg daily) or matched placebo. Baseline demographics, disease characteristics and organ screening data were collected, and participants were reviewed annually for endpoint measurements; CV events, SSc disease progression and mortality, with regular safety reviews between these annual visits. Participants were followed up for a period of 4 to 7 years. Results: Data analysis of the combination of the two measures (survival free from death or a cardiovascular event) demonstrated a trend towards favouring Iloprost over placebo but the difference was not statistically significant (Logrank test: Chi square=0.75, p=0.39). When time to a confirmed cardiovascular endpoint alone was examined there was a suggestion of a benefit from Iloprost, but the difference was again not statistically significant (Logrank test, Chi square =0.82, p=0.37). There was no statistically significant change in the rate at which organ screening endpoints occurred throughout follow-up, and for each endpoint there was no statistically significant difference between results in patients randomised to Iloprost compared to those randomised to placebo. Withdrawal from the treatment to which the patient was randomised was frequent with 97 (45%) of the total participants discontinuing study medication. ‘On treatment’ analysis, undertaken using the endpoint of death or confirmed cardiovascular endpoint, just failed to show statistical significance at the 5% level (p=0.054). Conclusion: The results of the SSTEP study showed that there was a trend towards favouring oral Iloprost over placebo in systemic sclerosis, though there was no statistically significant evidence to recommend its use to prevent disease progression. The high rate of withdrawal from both Iloprost and placebo hindered the possibility of demonstrating that Iloprost was effective in this study. It cannot be concluded that it is a useful therapy that may prevent premature mortality or progression to cardiovascular disease in this patient group.

A Narrative Analysis of Resilience and Coping in Persons Diagnosed with Multiple Sclerosis by Mildred C. Alford Ph.D., Ed., Berne International Graduate University, 1998 M.S. Ed., Texas A & M University, Commerce, 1989 B.S., Psychology, University of Houston, 1976 Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Health Psychology Walden University June 2017

Demyelination in the CNS is known to involve several immune effector mechanisms, including complement proteins. For this dissertation project the central hypothesis that C3 and downstream effector complement proteins exacerbate demyelination through activation of glial cells was tested. To investigate the role of C3 and downstream complement proteins in demyelination and remyelination pathology in vivo we utilized the cuprizone model. We used C3 knockout mice (C3-/-), which are lacking the central C3 protein and subsequently all downstream complement effector proteins, and transgenic mice expressing C3a or C5a under the control of the glial GFAP promoter. Interestingly, we found no changes in demyelination or remyelination pathology between C3-/- and control mice. However, C3a and C5a transgenic mice had exacerbated demyelination and slightly delayed remyelination in the corpus callosum compared to WT mice. Transgenic mice had increased cellularity in the corpus callosum due to increased activation and/or migration of microglia. There was also evidence of T cells in the corpus callosum during demyelination in C5a transgenic mice, suggesting C5a may modulate BBB permeability. During early remyelination oligodendrocytes migrated to the corpus callosum in higher numbers in C3a and C5a transgenic mice, thus enabling these mice to remyelinate as effectively as WT mice by the end of the ten week study. To determine the effects of anaphylatoxins on individual glial subsets, we created murine recombinant C3a and C5a proteins. We found that the MAPK pathway proteins JNK1 and ERK1/2 were activated in glia upon stimulation with recombinant anaphylatoxin proteins. When microglia and mixed glial cultures were stimulated with C3a and/or C5a, we observed an increase in the production of proinflammatory cytokines and chemokines. In contrast, anaphylatoxin-treated primary astrocytes had suppressed cytokine and chemokine production compared to untreated astrocytes. In vitro, primary microglia and astrocytes did not significantly migrate in response to stimulation with C3a or C5a proteins, suggesting migration may not be a primary anaphylatoxin-mediated function in the CNS. Overall, our findings show that anaphylatoxin production in the brain plays a negative proinflammatory role during demyelination and that anaphylatoxin proteins can activate individual subsets of glia, initiating the production of inflammatory mediators.

Thesis (M.S.)--University of Delaware, 2006. / Principal faculty advisor: Cheng-Shun (Richard) Fang, Dept. of Health, Nutrition, and Exercise Sciences. Includes bibliographical references.

Multiple Sclerosis (MS) is the most common demyelinating disease affecting the central nervous system. Over 80% of MS patients are in the relapsing remitting stage. Symptoms range from fever, fatigue, emotional distress, tingling, numbness, optic neuritis, spasticity, muscle weakness, impaired coordination, to other abnormal neurological problems. Expression of symptoms is known as a relapse or exacerbation. The cause of relapses is unknown, but multiple factors seem to play a significant role. Possible factors that may influence MS onset and relapse consist of a genetic association, viruses, disruption of the blood-brain barrier, and stress. Stress has shown to have negative implications and may stimulate relapses. Thus, this study examined a possible stress intervention that most people already had available to them, companion animals. Companion animals have been shown to lower blood pressure, decrease heart rate, provide social support, and reduce stress. The main hypothesis was to evaluate whether or not pet ownership and/or attachment influenced the perceived stress level and number of negative life events experienced by MS patients in the relapsing remitting stage. Participants were given a questionnaire that consisted of 7 surveys. The questionnaire accessed quality of life, disease severity, number of negative life events, perceived stress level, level of depression, social support, and pet ownership and attachment level. Our sample population consisted of MS patients seen at the University of Texas Southwestern Neurology clinic from February 23rd to May 21st, 2004. One hundred and forty seven relapsing remitting MS patients were included in the study. Multiple linear regression was used to compare the relationship of stress and number of negative life events to pet ownership and attachment. Results revealed that pet ownership and attachment levels did not affect the stress level and number of negative life events of MS patients. No confounders were identified. Interaction terms with disease severity as the dependent variable, pet ownership and perceived stress level or negative life events as the independent variables were not significant. The type of pet owned did not influence the attachment level of the MS patient. In conclusion, the results of this study did not support the hypothesis.

The effects of multiple sclerosis (MS) on the central nervous system often manifest as abnormalities in gait kinematics. Clinically practical, valid, and reliable measures of gait kinematics are necessary to address research and clinical questions about MS. Wireless flexible electrogoniometry (EG) is a clinically practical measure of joint angles. The GAITRite walkway system is a clinically practical, valid and reliable measure of temporal and spatial gait characteristics. The overall objective of this two-study research project was to explore whether these clinically practical measures of gait kinematics can be used to accurately detect gait abnormalities in people with multiple sclerosis. Study 1 examined the reliability and validity of EG and Study 2 examined the gait kinematics of people with MS (PWMS) using EG and GAITRite. For Study 1, angle at initial contact and total joint excursion were measured by EG at both the knee and ankle while ten healthy adults walked at a self-selected comfortable speed. Measurements were repeated for two testers and two visits to assess reliability. The same variables were measured concurrently with three-dimensional motion analysis (3D) to assess validity. For all variables, reliability was good as indicated by low measurement error and validity was good as indicated by association and agreement of EG with 3D. For Study 2, the same joint angles, along with speed, cadence, step length, stride length, stance duration and double support duration were assessed for six PWMS and six controls without MS. PWMS showed significantly reduced speed, cadence, and ankle excursion and increased stance and double support duration as previously shown with 3D. Spasticity and/or instability may lead to these kinematic gait abnormalities in PWMS; however, reduced velocity may confound this interpretation by affecting the other observed gait abnormalities. Further research about the determinants of gait dysfunction in PWMS is required. EG and GAITRite are clinically practical, valid and reliable measures of gait kinematics and should be included in further clinic-based research to determine which kinematic gait abnormalities are causes and which are effects of the observed decrease in gait speed in PWMS.

Cognitive impairment affects approximately half of multiple sclerosis (MS) patients. The Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) has previously demonstrated validity for detecting cognitive impairment in MS, and is quick and easy to complete. The objective was to validate an internet version of the MSNQ. The following were completed at home over the internet for 82 MS patients: (a) patient self-report version of the MSNQ (P-MSNQ), (b) informant version of the MSNQ (I-MSNQ), and (c) Centre for Epidemiological Studies Depression Scale (CES-D). Thereafter, patients completed in-office neuropsychological testing using the Brief Repeatable Battery of Neuropsychological Tests (BRB-N). Both the P-MSNQ and I-MSNQ were highly correlated with depression. The best-cut off score on the I-MSNQ was a 26, which gave a sensitivity of 72% and 60% for detecting cognitive impairment on the BRB-N. Given the modest sensitivity and specificity values, the MSNQ is not recommended for neuropsychological screening purposes over the internet.

Individuals with Multiple Sclerosis commonly use assistive mobility devices, such as rollators, to compensate for their mobility impairments. However, the effect of these devices on their foot placement during gait has not been explored in the community. The objective of experiment one was to develop and validate a tool that quantifies medio-lateral foot placement characteristics during rollator use. In this study, a technique was developed for an instrumented rollator (i.e. iWalker) and validated against a Vicon motion capture system in able-bodied young adults. The two systems were in strong agreement. The objective of experiment two was to apply this iWalker-based technique to individuals with Multiple Sclerosis to identify environment-related foot placement changes. This study revealed that step width variability, but not step width, can be influenced by certain outdoor environments. Therefore, environmental context is important to consider when investigating user-device interactions and factors responsible for safe mobility in this population.

Cognitive impairment affects approximately half of multiple sclerosis (MS) patients. The Multiple Sclerosis Neuropsychological Questionnaire (MSNQ) has previously demonstrated validity for detecting cognitive impairment in MS, and is quick and easy to complete. The objective was to validate an internet version of the MSNQ. The following were completed at home over the internet for 82 MS patients: (a) patient self-report version of the MSNQ (P-MSNQ), (b) informant version of the MSNQ (I-MSNQ), and (c) Centre for Epidemiological Studies Depression Scale (CES-D). Thereafter, patients completed in-office neuropsychological testing using the Brief Repeatable Battery of Neuropsychological Tests (BRB-N). Both the P-MSNQ and I-MSNQ were highly correlated with depression. The best-cut off score on the I-MSNQ was a 26, which gave a sensitivity of 72% and 60% for detecting cognitive impairment on the BRB-N. Given the modest sensitivity and specificity values, the MSNQ is not recommended for neuropsychological screening purposes over the internet.