Clinical heterogeneity in PSP (7 Japanese autopsy cases)

These Japanese researchers investigated the clinical symptoms of seven autopsy-confirmed PSP cases. Amazingly, “only three patients (42.9%) matched the clinical diagnostic criteria of PSP” at the time of death. “In addition, only one patient (14.3%) matched these criteria at the time of the initial symptoms. Such underdiagnosis of PSP was mainly caused by heterogeneity, variety of the timing, and presence of symptoms in exclusion criteria. The present study also demonstrated that the clinical features of PSP may change dramatically according to the disease stage. Target symptoms should be selected based on time and stage to optimize patient quality of life.”
Robin

Neuropathology. 2009 Jun 7. [Epub ahead of print]

Clinical heterogeneity in progressive supranuclear palsy: Problems of clinical diagnostic criteria of NINDS-SPSP in a retrospective study of seven Japanese autopsy cases.

Sakamoto R, Tsuchiya K, Mimura M.
Department of Neuropsychiatry, Showa University School of Medicine, Setagaya-ku, Tokyo, Japan.

Progressive supranuclear palsy (PSP) is known to display variable atypical clinical features. In the absence of clinical markers to diagnose PSP, neuropathological examination is the “gold standard” for diagnosis.

We retrospectively investigated clinical features in seven autopsy-confirmed cases of PSP. Only three patients (42.9%) matched the clinical diagnostic criteria of PSP proposed by the National Institute of Neurological Disorders and Stroke and the Society for PSP (NINDS-SPSP) at the time of death. In addition, only one patient (14.3%) matched these criteria at the time of the initial symptoms. Such underdiagnosis of PSP was mainly caused by heterogeneity, variety of the timing, and presence of symptoms in exclusion criteria. The present study also demonstrated that the clinical features of PSP may change dramatically according to the disease stage. Target symptoms should be selected based on time and stage to optimize patient quality of life.

PubMed ID#: 19508347 (see pubmed.gov for this abstract only; the abstract is available for free there)

Huntington’s discovery- it’s the protein,not the aggregation

This news about Huntington’s Disease was announced yesterday. Excerpts: “Scientists have solved a mystery surrounding a horrific illness: Why people with Huntington’s disease harbor a faulty protein throughout their bodies but it destroys only certain brain cells. … [That’s] the connection to other brain-destroying diseases… Most are distinguished by clumps of some type of faulty protein, and there’s a raging debate among scientists about whether the clumps, also called ‘aggregates,’ are the cause of brain destruction or a frantic attempt by the brain to save itself. ‘The answers in one disease may have implications for another,’ noted Koroshetz of NIH’s National Institute of Neurological Disorders and Stroke. ‘There’s been people on both sides of the fence. This story plays to the role of the aggregates as not being the major problem but the soluble protein as being the major problem’.”

The protein involved in PSP and CBD is tau.

Two, similar articles are copied below. (I read one on an MSA-related online discussion group.)

http://hosted.ap.org/dynamic/stories/U/ … NS_MYSTERY

Jun 4, 2:00 PM EDT

Scientists uncover culprit in Huntington’s disease
By LAURAN NEERGAARD
AP Medical Writer

WASHINGTON (AP) — Scientists have solved a mystery surrounding a horrific illness: Why people with Huntington’s disease harbor a faulty protein throughout their bodies but it destroys only certain brain cells.

The discovery may provide a long-awaited target for developing treatments for the incurable killer – and also may have ramifications for more common brain diseases like Alzheimer’s.

“Up until now, nobody had the vaguest notion of what was the cause of the brain damage and the death,” said Dr. Solomon Snyder of Johns Hopkins University, whose team reported the findings in Friday’s edition of the journal Science.

“This is a significant step forward,” said Dr. Walter Koroshetz, deputy director of the National Institutes of Health’s brain division.

Huntington’s is a rare inherited disease – there are an estimated 30,000 U.S. patients – that typically strikes in the late 30s or early 40s. What starts as uncontrollable twitches and jerks and deterioration of mental abilities inexorably worsens until patients can barely eat, speak or walk. Death occurs a decade or more after symptoms begin.

One mutated gene is the cause. A child of a Huntington’s patient has a 50-50 chance of inheriting that gene, and anyone who does will develop symptoms at some point if they live long enough. Scientists discovered the gene in 1993, giving families the hard choice of whether to be tested to learn who escaped that fate and who didn’t.

But 16 years later, there is only one treatment to ease the writhing movements and little progress toward the bigger goal – finding some way of slowing or stopping the disease from carving a hole in patients’ brains.

Enter the new research. The bad Huntington’s gene creates a faulty protein that’s found in all cells. Yet the only cells that die are certain neurons, mostly those in a movement-controlling brain region called the corpus striatum that by the time patients die is so ravaged that it’s tissue-paper thin.

Why? A second protein is the culprit, Snyder’s team discovered. It’s a little-known molecule named Rhes that is found almost exclusively in the striatum. When Rhes mixes with the mutated Huntington’s protein it sparks a chemical reaction, the researchers reported.

First came a simple experiment: They used human embryonic cells and brain cells taken from mice. To each, they mixed in different combinations of the mutated Huntington’s protein, its normal version, and Rhes. Only when both the mutant protein and Rhes were in the same cells did those cells start dying.

Then the researchers teased out just what made the chemical reaction, named sumoylation, so toxic. It seems that cells may try to deal with the mutated protein by clumping it out of the way, almost like creating a garbage heap. Adding Rhes led to less clumping along with cell death, suggesting that it’s the soluble form of the faulty protein that’s dangerous.

And that’s the connection to other brain-destroying diseases like Alzheimer’s. Most are distinguished by clumps of some type of faulty protein, and there’s a raging debate among scientists about whether the clumps, also called “aggregates,” are the cause of brain destruction or a frantic attempt by the brain to save itself.

“The answers in one disease may have implications for another,” noted Koroshetz of NIH’s National Institute of Neurological Disorders and Stroke. “There’s been people on both sides of the fence. This story plays to the role of the aggregates as not being the major problem but the soluble protein as being the major problem.”

Dr. Nancy Wexler of the Hereditary Disease Foundation, who helped lead the Huntington’s gene discovery, called the work a “fabulous experiment” and praised the Hopkins team for quickly publishing the Rhes reaction so that other researchers could start hunting ways to block it.

“This is a very promising avenue,” she said.

One next step is to see whether removing Rhes from mice with Huntington’s disease slows or prevents the brain cell death without causing too many side effects. If so, the quest would be for a drug to block that protein.

© 2009 The Associated Press.

http://www.sciencedaily.com/releases/20 … 144330.htm

Mystery Solved: Tiny Protein-activator Responsible For Brain Cell Damage In Huntington Disease

ScienceDaily (June 5, 2009) — Johns Hopkins brain scientists have figured out why a faulty protein accumulates in cells everywhere in the bodies of people with Huntington’s disease (HD), but only kills cells in the part of the brain that controls movement, causing negligible damage to tissues elsewhere. The answer, reported this week in Science, lies in one tiny protein called “Rhes” that’s found only in the part of the brain that controls movement. The findings, according to the Hopkins scientists, explain the unique pattern of brain damage in HD and its symptoms, as well as offer a strategy for new therapy.

HD itself is caused by a genetic defect that produces a mutant version of the protein “huntingtin” that gathers in all cells of the body, but only seems to affect the brain. Passed from parent to child through an alteration of a normal gene, HD over time causes irreversible uncontrolled movement, loss of intellectual function, emotional disturbances and death.

“It’s always been a mystery why, if the protein made by the HD gene is seen in all cells of the body, only the brain, and only a particular part of the brain, the corpus striatum, deteriorates,” says Solomon H. Snyder, M.D., professor of neuroscience at Johns Hopkins. “By finding the basic culprit, the potential is there to develop drugs that target it and either prevent symptoms or slow them down.”

Curious about the huntingtin protein’s striatal-specific effect, Snyder’s research team, led by Srinivasa Subramaniam, Ph.D., a postdoctoral fellow, searched for proteins that interacted locally, specifically and exclusively with huntingtin in the corpus striatum, guessing that the molecular answer to the mystery most likely would be found there.

The protein Rhes caught their attention because they already were studying a related protein for other reasons. Rhes was known to be found almost exclusively in the corpus striatum.

Conducting tests using human and mouse cells, they found that Rhes interacted with both healthy and mutant versions of huntingtin protein, but bound much more strongly to mutant huntingtin, also known as mHtt.

“Touching or binding is one matter, but death is altogether another,” said Snyder, so the next step was to see whether and how Rhes plus mHtt could kill brain cells in the corpus striatum.

Using human embryonic cells and brain cells taken from mice the researchers added different combinations of normal and mutant huntingtin and Rhes, and examined the cells over the next week to see if any cells died.

While each protein alone didn’t change the number of cells in the dishes, when both mHtt and Rhes were present in the same cells, half the cells died within 48 hours.

“Here’s the Rhes protein, we’ve known about it for years, nobody ever really knew what it did in the brain or anywhere else,” says Snyder. “And it turns out it looks like the key to Huntington’s disease.”

Snyder’s team then went on to tackle another mystery surrounding the disease, the solution to this one adding further evidence for the role Rhes plays in HD.

“We’ve known for a long time that abnormal huntingtin proteins aggregate and form clumps in all cells of the body, but the corpus striatum of HD patients seems to have fewer of these clumps than other brain regions or the rest of the body,” says Subramaniam in describing the mystery. “This has led to much controversy: Are the clumps toxic, or is it the lack of clumps that’s toxic to these brain cells?”

In their experiment, adding Rhes to cells with abnormal huntingtin led to fewer clumps, but the cells died. The results, says Subramaniam, suggest that Rhes might be responsible for unclumping mutant huntingtin protein and this somehow kills cells. “Since Rhes is highly found in the corpus striatum, clumping somehow protects cells in other tissues of the body from dying,” says Subramaniam.

Subramaniam and the rest of Snyder’s research team currently are exploring whether removing Rhes from mice with Huntington’s disease can slow or stop brain cells from dying.

“Now that we’ve uncovered the role of Rhes, it’s possible that drugs can be designed that specifically target Rhes to treat or even prevent the disease,” says Snyder.

This study was funded by a U.S. Public Health Service grant and Research Scientist Award.

Authors on the paper are Srinivasa Subramaniam, Katherine Sixt, Roxanne Barrow and Solomon H. Snyder, all of Johns Hopkins.

Adapted from materials provided by Johns Hopkins Medical Institutions, via EurekAlert!, a service of AAAS.

Cerebellar involvement in PSP (22 confirmed patients)

Clinicopathological studies are the gold standard for any medical research. These sorts of studies find brains of those with certain diseases and then refer back to the patients’ medical records to see what observations can be made and lessons learned.

This Japanese clinicopathological study looks at 22 patients with path-confirmed PSP. I think the most recent Williams/UK study looked at 85 patients.

“10 patients were categorized as having RS, and 8 were categorized as having PSP-P. Four patients presenting with cerebellar ataxia or cerebral cortical signs were categorized as having unclassifiable PSP. Among them, 3 developed cerebellar ataxia as the initial and principal symptom.” This study “demonstrates that PSP patients manifest cerebellar ataxia.” (Dr. David Williams came up with the classification of RS or Richardson’s Syndrome and PSP-P or PSP-Parkinsonism. His research since 2005 or so describes these two main types of PSP.)

Robin

Movement Disorders. 2009 May 1. [Epub ahead of print]

Cerebellar involvement in progressive supranuclear palsy: A clinicopathological study.

Kanazawa M, Shimohata T, Toyoshima Y, Tada M, Kakita A, Morita T, Ozawa T, Takahashi H, Nishizawa M.
Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan.

The clinical heterogeneity of progressive supranuclear palsy (PSP), which is classified as classic Richardson’s syndrome (RS) and PSP-Parkinsonism (PSP-P), has been previously discussed. We retrospectively analyzed 22 consecutive Japanese patients with pathologically proven PSP to investigate the clinicopathological heterogeneity. We investigated the clinical features both early in and at any time during the disease course. The pathological severities of neuronal loss with gliosis and tau pathology were also evaluated. On the basis of the clinical features, 10 patients were categorized as having RS, and 8 were categorized as having PSP-P. Four patients presenting with cerebellar ataxia or cerebral cortical signs were categorized as having unclassifiable PSP. Among them, 3 developed cerebellar ataxia as the initial and principal symptom. Notably, tau-positive inclusion bodies in Purkinje cells were significantly more frequently observed in the patients with cerebellar ataxia than in those without cerebellar ataxia. All the patients with cerebellar ataxia exhibited more neuronal loss with gliosis and higher densities of coiled bodies in the cerebellar dentate nucleus than those without cerebellar ataxia. This study confirms the wide spectrum of clinicopathological manifestations associated with PSP regardless of different ethnic origin, and demonstrates that PSP patients manifest cerebellar ataxia.

PubMed ID#: 19412943 (see pubmed.gov for abstract only)

“PSP and PT” article in physical therapy newsletter

There is a good article in TodayinPT (todayinpt.com), a newsletter for physical therapists, about Cris Zampieri’s research (described in detail in a March 2009 post).

This article for the PT community is easy reading compared to the medical journal article!  It’s wonderful this research into PSP is reaching a broader PT community.  It’s one of the most hopeful pieces of research I’ve read on PSP!

At the bottom of the TodayinPT article, there’s a short comparison of PSP and PD, taken from NINDS (ninds.nih.gov).

Robin

———————————

news.todayinpt.com/article/20090330/TODAYINPT0104/90327004

PSP and PT
A Rare Disease Responds To Therapy
By Mark Cantrell
TodayinPT, Monday March 30, 2009

PTs who have never treated a patient with progressive supranuclear palsy are not alone. The disease is so rare that only now are clinical studies emerging that prove the benefit of physical therapy intervention for the population. Whereas more than half a million Americans are diagnosed with Parkinson disease, PSP is much less common, affecting 20,000 people nationwide.

PSP is a Parkinson-like condition that affects walking, balance, mobility, vision, speech, and swallowing. Affected individuals first notice balance difficulties that can cause spontaneous dizziness and sudden falls, and often experience problems with their vision, especially an inability to look downward.

“We don’t know why that happens,” says Cris Zampieri, PT, PhD, a postdoctoral fellow at the Neurological Science Institute at Oregon Health and Science University in Portland. “There is an area in the brain stem that controls eye movement, and when those neurons degenerate, it affects vision. But no one knows if it’s environmental, familial, or genetic.”

PSP is caused by a slowly progressive degeneration of brainstem nuclei with a typical onset in late middle age. Although PSP is not directly life-threatening, individuals with PSP are more susceptible to head injuries and fractures from unexpected falls, and pneumonia from impaired swallowing.

A Visionary Study

Because little research had been done on the subject, Zampieri and her colleague and mentor Richard Di Fabio, PT, PhD, developed a small clinical study that combined treatment for both eye movement and balance problems in people with PSP. Nineteen moderate-stage patients took part in the survey, with roughly half in a balance-only group and the other half given exercises for both balance and eye movement deficits. “The exercises included going from sitting to standing, walking in tandem, abduction exercises, and so on, along with eye movement exercises,” Zampieri notes.

Because there were no guidelines in the literature for developing such a program, the team had to be creative in constructing the study. “We pulled together information from other populations and studies as to what they had found effective to develop our protocol,” Zampieri says. “No one had integrated eye movement with gait and posture studies, yet it’s a normal neuromechanism that we all need in order to function.”

Moderate to large improvements in gait and eye movement was seen in the dual-therapy group, with only small benefits for the balance-only cohort, she reports: “It was a preliminary study that involved just a small group of subjects, but I think the main message is that when you associate eye movement training with balance training, you get more benefits than with balance training alone.” A larger study involving more subjects is in the planning stages.

Benefits in the Balance

At the University of Texas Medical Branch School of Health Professions in Galveston, Elizabeth J. Protas, PT, PhD, FACSM, created her own pilot study of PSP and balance problems. Protas, professor and chair of the department of physical therapy, was impressed with the Zampieri-Di Fabio trial due to its scope. “I really must compliment them, because getting 19 [patients with] PSP together is almost a miracle,” she says.

Protas became interested in studying balance when a nursing home resident with PSP came to her program after experiencing frequent falls. “His wife wanted to keep him safe, but I failed; I couldn’t help this guy, even though I tried everything I could think of to make him more stable. I found that walkers aren’t the answer for these people, because even while using one they fall over sideways or backward.”

Protas’ study concentrated on exercises to prevent falls, a symptom that, unlike PD, manifests itself early in the course of the disease. There are other differences as well, Protas says. “[With] PSP, [a] patient’s walk is entirely different than with Parkinson’s,” she explains. “They exhibit something called a cavalier gait: almost a kind of swagger, usually followed by a fall. Someone with Parkinson’s walks with very small steps, is very slow, and doesn’t have a lot of trunk and arm movement, whereas the person with PSP has an arm swing and a regular walking stride, but no postural responses.”

For the study, Protas’ nursing home resident was given 1 1/2 hours of exercise three days per week for eight weeks, using walk training, balance perturbation, and step training on a treadmill while strapped into a body support harness for safety reasons. “It took us about three to four weeks before we saw noticeable improvement,” Protas says. “When I saw the data, I could hardly believe it, because I had come to the point where I didn’t think we’d ever be able to help. I never would have predicted we could have helped him and made that much change. It was one of those wonderful moments in clinical science.”

Ongoing Gains

At Concordia University in Mequon, Wis., professor of physical therapy Teresa Steffen, PT, PhD, had a patient with PSP of her own who suffered from frequent falls. After reading Protas’ paper, she set up a treadmill training regimen for the patient, a 72-year-old former dentist who was six years post-diagnosis. The sessions lasted for 2 1/2 years, and during that time he also participated in an exercise group for patients with PD.

The outcome was a success, Steffen reports. The patient’s incidence of falls has decreased markedly, and today he is still ambulating with the aid of a walker, lives at home with his wife, and is very involved in his community. Now 75, he has continued his exercise regimen twice per week since the study ended.

Steffen stresses the importance of a long-term, ongoing exercise program for patients with PSP. “It’s not something you can do for a while and quit and be better,” she says. “It’s forever or forget it. To get this motor learning, patients really have to practice.”

Mark Cantrell is a medical writer for the Gannett Healthcare Group. To comment, e-mail [email protected].

More Info – PSP vs. PD
Due to its similarity to other neurodegenerative conditions, PSP is often misdiagnosed, usually as PD, which can lead to inappropriate treatment.
Patients with PSP
• Tend to stand straight or with heads tilted slightly back; tend to fall backward
• “Cavalier” swaggering gait pattern; normal trunk movement and arm swing
• Speech and swallowing problems more severe, starting earlier
• Eye movement abnormal, blurred vision
• Tremor rare
• Respond poorly to levodopa
Patients with PD
• Usually bend forward
• Slow, shuffling gait pattern; little trunk movement or arm swing
• Speech and swallowing problems less severe, starting later
• Eye movement close to normal
• Tremor common
• Respond well to levodopa
Source: NIH, NINDS: www.ninds.nih.gov.

More Info – Resources
• Steffen TM, Boeve BF, Mollinger-Riemann LA, Petersen CM. Long-term locomotor training for gait and balance in a patient with mixed progressive supranuclear palsy and corticobasal degeneration. Phys Ther. 2007; 87(8): 1078-1087.
• Suteerawattananon M, MacNeill B, Protas EJ. Supported treadmill training for gait and balance in a patient with progressive supranuclear palsy. Phys Ther. 2002; 82(5): 485-495.
• Zampieri C, Di Fabio RP. Balance and eye movement training to improve gait in people with progressive supranuclear palsy: quasi-randomized clinical trial. Phys Ther. 2008; 88(12): 1460-1473.

 

Hypersexuality and PSP?

I received this question via email today:

Did you find or have you heard anything about heightened sexuality with PSP patients, for older and more challenged patients, specifically women who find a need to masturbate?

My answer is:

As I’m pretty sure I’ve discussed elsewhere on the Forum, my father did grab CNAs and private caregivers we had hired in inappropriate places (breasts, crotch). This was not in keeping with his past prudish/modest/respectful behavior. Because PSP can affect the frontal lobe, society’s rules are somewhat out the window. There is a lack of inhibition. And certainly hypersexuality is possible.

You may have luck treating this with a mood stabilizer. But it’s likely refractory to medication. Well, you can sedate the person but this is typically unacceptable to many.