The Society of British Neurological Surgeons (SBNS) & Association of British Neurologists (ABN) Joint Conference,Read Now
By Shirley Widdop
The Society of British Neurological Surgeons (SBNS) & Association of British Neurologists (ABN) Joint Conference, Queen Elizabeth II Centre, London 19 - 21 September, 2018.
The joint conference of the BSNS & ABN was the ideal opportunity for Director, Dr Benjamin Davies, Researcher, Dr Michelle Starkey, Public Relations Professional, Delphine Houlton & Myelopathy Support on Facebook volunteer admin, Shirley Widdop, to raise the profile of the newly-formed charity, Myelopathy.org
Over three days, we hosted our inaugural trade stand at the event in order to publicise the work of Myelopathy.org & also advertise to the attendees that there is now, finally, somewhere their newly diagnosed patients can turn to for information, help & support.
Our presence was very well received by many of the delegates, notwithstanding the lure of colour co-ordinated M&Ms carrying the Myelopathy.org logo & the hashtag #myelopathymatters, alongside stripey peppermint candy canes - alluding to the fact that many of our members need to use mobility aids.
A rather superb magnum of champagne was on offer as a prize for a fiendishly-difficult Degenerative Cervical Myelopathy quiz as devised by Ben for the delegates to attempt. Many thanks to Berry Bro. & Rudd (www.bbr.com) for their most excellent & generous donation.
What was striking about our three days at the conference was the enthusiasm with which we were welcomed by the delegates. We spoke & networked with many medical & allied health professionals from both the private & public services sectors &, much to our joy & delight, received many offers of collaboration in return, which can only help improve patient outcomes for those diagnosed with myelopathy.
The main messages that we kept hearing from delegates centred around the current lack of awareness regarding myelopathy, the lack of a joined up approach to research & most worryingly, as divulged by several neurosurgeons, was the fact that by the time patients with myelopathy are referred to neurosurgical services, it is often too late to improve their function & mobility, hence the reason that patients are left with life-limiting & life-long disability. However, with the official charity launch of Myelopathy.org due in 2019, hopefully change is on the way.
On a final note, we would like to thank the SBNS (www.sbns.org.uk) & ABN (www.theabn.org) for allowing us the privilege & pleasure of attending conference. In addition our grateful thanks is also extended to The Queen Elizabeth II Centre (www.quiicentre.london) for its impeccable hosting - the facilities & catering in particular were top notch. On a personal note, I would like to thank QEII Centre from the view of someone with a disability; the venue was one of the most accessible & welcoming venues I have been to. Nothing was too much trouble, even to the point of allowing me to park on the forecourt for the duration of conference. I am sincerely grateful. Many thanks.
PS. Roll on 2019 - the Myelopathy.org conference stand will in attendance at the British Association of Spine Surgeons (BASS) Conference in Brighton from the 3-5 April. We’ll keep you posted.
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?
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
As a Myelopathy.org Community Champion, I had the honour of holding the charity’s first fundraiser at my local football club.
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.
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.
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.
By Timothy Boerger
Reviewed by B.Davies
Neck Muscles and CSM– An Update Part 1 of 2
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.
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?
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
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.
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).
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.
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,
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:
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.
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:
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.
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”.
JOIN OUR INSIGHT TIMER CERVICAL MYELOPATHY
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.
Reviewed by. BM Davies
Reason for the Study
Walking impairments are a common feature of cervical myelopathy and can lead to falls. In elderly individuals such falls, even if minor, can lead to injuries, such as broken bones. Broken bones (‘fractures’) are more common as we get older, as aging affects bone strength, including conditions such as osteoporosis. Such fractures generally occur in stereotyped locations such as the wrist, shoulder, hip, and low back and therefore termed ‘fragility fractures’. These secondary injuries are associated with a significant impact on life, including in some cases death. In 2015, a group from the USA showed that 18% of patients with a hip fracture had undiagnosed myelopathy . However the overall rate of fragility fractures (a fall related injury also associated with fragile bones) amongst elderly individuals with cervical myelopathy has not yet been investigated 
How was this study done?
This study was conducted by searching a database of Medicare patients (meaning previously collected anonymous medical data from individuals in the United States age 65+). This study included 24,439 patients with cervical myelopathy who had undergone surgery, 35,893 patients with cervical myelopathy who had not undergone surgery, and 831,532 patients without myelopathy who had a general medical appointment during the study timeframe of 2008-2011.
For this study, the researchers excluded patients who might confuse the data (e.g. those who had a neck surgery unrelated to cervical myelopathy or history of cancer, infection, or trauma to the spine, but also those with a history of fragility fractures). The researchers then tracked the occurrence of fractures over the next 3 years and used statistical tests to account for differences in study groups which could influence the results (e.g. age, sex or diagnosis of osteoporosis).
What did they find?
There were some differences in the characteristics of the study groups:
At 12 months follow up, both non-operative and surgical cervical myelopathy groups were more likely to sustain fragility fractures than controls. The odds ratios were 1.59 and 1.48 respectively (odds ratios indicate relative odds of a diagnosis or injury with a value closer to 1 indicating no difference). Further, the odds of fracture were higher in both groups than controls at 36 months as well, however, at 36 months the surgical group was lower than the non-operative group.
Why is this important?
There are some limitations to this study; first, because this was a search of a Medicare database it is most applicable to patients with cervical myelopathy 65 and older, but also due to the type of data recorded, there are some possible factors related to falls the researchers were unable to account for such as BMI or physical activity.
However, this is an extremely large study which gives us confidence the results are real, and not simply a coincidence.
Hopefully these findings will help to raise the profile of myelopathy; as 1) the impact and cost of fragility fractures is significant for healthcare providers, 2) myelopathy is not routinely considered as part of managing a patient’s falls risk and 3) falls assessments are carried out by general professionals.
Whilst surgery did not eliminate the risk of fragility fractures, they were reduced in those that had surgery. It would appear from the characteristics of the study groups, that age and ill-health were more likely to lead to conservative management of cervical myelopathy and whether or not this is appropriate, given the potential significance of fragility fractures will need further investigation.
 Radcliff et al (2015). High Incidence of Undiagnosed Cervical Myelopathy in Patients with Hip Fracture Compared to Controls. Journal of Orthopaedic Trauma. http://doi.org/10.1097/BOT.0000000000000485
 Horowitz JA, et al (2018). Fragility Fracture Risk in Elderly Patients with Cervical Myelopathy. Spine.
(3) Can Cervical Myelopathy cause hip fractures
We are very happy to welcome Frank Dutton to our team,Frank was diagnosed with cervical myelopathy in 2015 and is currently leading our fundraising efforts as a Charity Ambassador.If you have any fundraising ideas or want to raise money for our cause you can email Frank directly at the bottom of the page.
Frank's Background Story
My whole life was driven by sport, mainly encouraged by my Granddad, and I played both football and Ice-hockey at an early age, the latter for a living. A severe knee injury forced me to hang my boots up but I continued being involved in sport only this time I took on the role of a goalkeeping coach in football, working with all age groups in both Milton Keynes and Bedford. An innocuous dive for a ball during a coaching session on the 27th September 2008 was to change my life drastically. I landed awkwardly on my arm and the elbow dug into my lower abdomen. A few hours later I was rushed into A&E and despite breaking bones and tearing ligaments during my career this was at a level I had never truly experienced before.
Roughly a year and half later I was referred to Addenbrookes hospital pain management team, and they diagnosed I had torn a stomach muscle, for the second time in my life, but had also damaged nerve endings and I was now suffering from Chronic Pain Syndrome and due to the damage done to my nerve endings, I would probably suffer from that for the rest of my life. To go from being so physically active to not being able to move without causing any pain was very hard to accept and then having to endure things such as having to be pushed around in a wheelchair where I had become so weak was tough and mentally I have constantly struggled to come to terms with it. Thankfully my partner Lucy has helped me to learn to deal with these emotions and in 2010 she encouraged me to enrol on an Access Course at Bedford College with a view to going to University and begin training as a Primary School Teacher. For someone who had left school with no qualifications to speak of, and to go to college was really scary but I enjoyed my time there, and I even wrote an article for the college paper about being a mature student struggling with a disability. I passed the course with merits and distinctions and gained a triple distinction for my final dissertation. I was speechless at how well things had gone and I was even more amazed when the University of Bedfordshire accepted me onto their Early Years Education, 3 year BA Hons degree. Whilst at Uni I knew the typical student nightlife was never going to be an option however I wanted to get involved as much as I could and so I became a Course Rep, a PAL leader during my 2nd and 3rd years, which involved helping first year students negotiate their first two terms on campus, and I also volunteered as a Student Ambassador, which involved helping out on Open Days showing prospective students around the campus and giving talks both on campus and in local colleges and schools about my experiences of being a student as well. This all helped me to gain confidence in myself and I found myself being asked to become a mentor to disabled students who were finding it difficult to adjust to university life. As I had done at college, I also found myself writing an article for the university magazine about how I’d gone from playing hockey to being a student wanting to work with children. My health continued to make things difficult but the university were superb and with an added year I eventually graduated in the July of 2015. Despite the issues I had endured, I enrolled onto the PGCE course to gain my teachers qualification. My health unfortunately took a turn for the worse, and I began to have constant tingling in my left arm and I had started to pass out with an alarming frequency.
Eventually I had to accept things were not getting better and I withdrew from the course on the 17th November which was one of the lowest points in my life. In January 2016 I applied for a job at the university working with the Dean of Student Experience and was offered the job on a 6 month contract. The role meant talking to students and finding out what issues they had experienced as well as contacting other universities to see what things they were initiating to get students involved more. During my time in this role I was instrumental in the starting of a student society called PAMMS, which was for parents and mature students, a student group I felt were regularly missed during student life and events. I was still passing out regularly and in late May 2016 that problem eventually caught up with me. I was in the garden playing with my dogs when I passed out, and upon coming round I was surrounded by broken wood and a concerned dog licking my face, it became clear I had gone through a small garden table and had badly bruised my left arm. A trip to A&E showed I hadn’t broken any bones but my arm was still extremely sore and had swollen quite alarmingly. The arm continued to swell and a few days later the whole forearm was black with bruising and was so painful I couldn’t bear anything touching my arm, leading to another trip up to A&E. A succession of specialists and nurses took it in turns to look at my arm and I was eventually taken to a ward before having surgery to repair the Compartment Syndrome which I was now suffering from. A CT and an MRI scan back in February of 2016 had already shown I had issues with 5 discs in my neck and that these were pressing on my spinal cord. In the August 2016 after seeing the neurology department at Cambridge hospital I had an ACDF to repair my C4/5 discs, however the surgeon stated I would need further surgery to repair the other levels. Another knock to my left hand caused my arm to swell again, and another trip to A&E led to me being rushed to surgery in late November 2016 to repair a second Compartment Syndrome, this time on the inner half of my left arm. I have been left with two 7* inch long scars on my left arm, and I was still continuing to pass out on a regular basis, and a further MRI scan in March of 2017 showed the discs in the neck had got worse and I needed major surgery to repair things. Lucy and I got married in late July and enjoyed a superb Honeymoon in Wales later on in September. My surgery was scheduled for 11th December and unfortunately was postponed three times, however, I reported to Addenbrookes on the 24th January 2018 for surgery the day after.
My surgery was to be a posterior fusion from C2-T1 with a laminectomy of C3/4/5. Due to the issues with the arm I had been diagnosed with an Acquired Severe Bleeding Disorder and thus needed platelets and other blood cultures to try to ensure there were no complications during the surgery. Trust me to make it a problem as an issue with controlling the bleeding along with the intricate metal work being inserted into my neck meant I was in theatre for just over 8 hours before being taken to critical care to begin the recovery.
I woke up and to be honest for the first 36 hours I felt pretty good, I think the copious amounts of Ketamine and morphine being pumped into my body may have had something to do with it. Lucy came to visit the day after surgery and couldn’t believe how coherent I was and in how little pain I appeared to be, this would definitely not be the case the day after, once I had been transferred to a Neuro ward and the Ketamine had worn off. I felt like I had been hit by a train and any movement sent fresh waves down my neck and back, and I couldn’t believe how uncomfortable the neck brace was either, even a morphine pump struggled to keep up with the need for pain relief as my body tried to cope with what had just happened. Over the next two weeks I gradually recovered and was allowed home, with the knowledge I had to keep the brace on for 24 hours a day and I would be seen in around 3 months time. The recovery process at home was hampered by an issue with sciatica which prevented me from laying in a reclined position in my bed forcing me to spend the first three months after the surgery sleeping on my sofa. This was really difficult to cope with but Lucy kept me going and I made sure the sympathy mode was kept up with wine gums and jelly babies being to the fore of my food intake. Lucy was able to take me out for a coffee on the odd occasion and my pain levels slowly reduced although even now 6 months down the line I am still having issues with the pain in the surgery site as the muscles begin to knit back together. My Chronic Pain has obviously not helped and has at times left me reaching for the oramorph as the pain relief I am already on had not controlled things. I have good and bad days and occasionally I have a very bad day which leaves me barely able to move. On a plus side I am no longer passing out 3-4 times a day, which when you think about it, I have been passing out for nearly 18 months, so at a best guess, I’ve zonked out over a 1,000 times.
I am now well on the road to recovery and despite still having issues with my shoulders and trying to get used to having a limited range of movement in my neck, having the surgery was worth it and indeed was necessary. My surgery was for prevention rather than cure and I know that whilst I wont ever score the winning goal in a Stanley Cup Final, I’m now looking forward to the future with confidence and this role is the perfect opportunity for me to continue with my recovery and make the most of the superb work done by my surgeon Dr Mark Kotter. It was Mark that explained myelopathy to me before I had my surgery and told me about the Facebook support group which I subsequently joined and that has been such a great support to myself and my wife. It has also helped me understand my condition more with the information available and accounts from others who suffer this tough condition. When the group got the great news it was becoming a charity I really felt I wanted to be involved and to help spread he awareness of this condition and to raise funds. After speaking to the team I have been given the great opportunity to become the charity Ambassador for Myelopathy.org and hope that I can help to spread the word and begin to help people to understand the condition and thus give support to both sufferers and their loved ones.
By Timothy Boerger
Edited by Benjamin Davies
Research Summary on MRI Methods for Predicting Functional Recovery from Surgery in Patients with Cervical Myelopathy.
Rao A et al., Diffusion Tensor Imaging in a Large Longitudinal Series of Patients With Cervical Spondylotic Myelopathy Correlated With Long-Term Functional Outcome. Neurosurgery. Epub ahead of print Feb 23, 2018
Reason for the study
Currently, the assessment of the impact of cervical myelopathy is based largely on patient reported symptoms and commonly quantified using an assessment scale called the mJOA. Patient reported symptoms are very important to take into account when discussing disease severity and function, but imaging measures which explain symptoms are also helpful. Currently there has been limited success in developing imaging measures which explain symptoms and, perhaps more importantly, predict future symptoms and potential recovery following surgery. This last part will be especially important for patients and surgeons determining who will benefit from surgery.
This study examined a different magnetic resonance imaging (MRI) technique than normal, called diffusion tensor imaging. This technique quantifies how water naturally flows (diffuses). The specific measure they chose (fractional anisotropy) measures the degree to which water flows in a single direction on a scale of 0 to 1 with values closer to 1 indicating diffusion more strongly in 1 direction. In axons of the spinal cord, for example, it would be expected that water would flow consistently along the path of axons rather than perpendicular to the axons. If a group had a worse score, however, it might indicate that they had damage to the neurons allowing water to move more freely. So, the purpose of this study to use fractional anisotropy as a measure of integrity of neurons in the spinal cord and see if this correlated with function pre-surgically and change in function following surgery.
This study enrolled patients who were diagnosed with cervical myelopathy over a 5 year period (age range 33 – 81, 18 male, 26 female) and followed these patients for 2 years following surgery. They took their MRI scans and determined mJOA score pre-operatively. For this study they focused their imaging analysis at the spinal level with the greatest compression of the spinal cord. For this analysis they included the whole cord except for the border around the cord because the data they could gain from this area might be incorrect due to the surrounding cerebrospinal fluid. They then compared the MRI scans (fractional anisotropy) and mJOA pre-operatively, and 6-, 12-, and 24-months after surgery. They also compared fractional anisotropy values to those from a group of healthy control participants.
As expected fractional anisotropy (the MRI measure of neuron integrity) was lower in patients with cervical myelopathy than controls. It was also associated with the severity of myelopathy before surgery, as assessed by the mJOA (a measure of patient function).
Also, fractional anisotropy inversely predicted change in mJOA score at 12 months, but was less strongly predictive of change in mJOA at 6 and 24 months. Baseline mJOA also was inversely predictive of change in mJOA at 12 months. This means that in this study, those participants with lower fractional anisotropy (neural integrity) or mJOA (function) scores pre-operatively improved the most following surgery.
Why is this important?
At present, we are unable to predict accurately the response to surgery, and therefore markers which help this will be useful for doctors and patients. Whilst fractional anisotropy, has been investigated before previous studies using this technique were less successful in drawing a relationship with function. This may be due to improving the methods of collecting and analyzing the MRI data.
The identified relationship between baseline mJOA and change in mJOA with surgery are therefore promising, but require further research to understand the meaning for patients; for example it is recognized that patients with greater disability typically do improve more as measured by the mJOA, but that does not mean that they achieve a better functional outcome.The mJOA is not a linear scale, where each point gain is equally as important as the next.
We look forward to watching our understanding of Fractional Anisotropy improve and if it can be of benefit to doctors and patients.
Swelling is a common reaction of your body to any form of injury; remember the last time you banged your finger, or perhaps twisted your ankle? So unsurprisingly, it can happen to the spinal cord and has been reported in patients with CSM. However, it is not present in all patients and its significance is not certain. In addition to this, some studies have now described that the spinal cord can swell after surgery. The reason for this is unclear and equally what it means for patients is not clear.
On basic MRI imaging, swelling is not that easy to detect; a doctor may look for a slight enlargement of the spinal cord or some signal change. An alternative method is to inject a ‘contrast agent’ into the patient during the scan. This is a special form of dye which highlights certain processes, and can be a indicator of swelling amongst other things. We call this ‘highlighting’ enhancement.
On this basis, a group from Japan have been looking at spinal cord swelling using contrast and what it means for patients.
What did the study measure?
The team from Japan performed ‘contrast MRI’ scans on patients with CSM due to undergo and operation, before and after their surgery. They then compared what happened to patients who had enhancement and those that did not have enhancement.
What were the results?
In the study they found that those with preoperative enhancement were more likely to have developed swelling at 1 month after the operation and the swelling was more likely to persist until 1 year post operation. Those who developed swelling had poorer outcomes as assed by a scoring system called the JOA that looks at movement skills as well as sensory loss (problems with feeling).
What does this mean for those affected?
This sort of MRI imaging is not normally performed during the work up for CSM, but the potential to offer additional information into the severity of the disease and how patients are likely to respond to surgery would be helpful to doctors and sufferers alike.
It is worth noting that the injection of dye can be harmful to some people, although this is uncommon.
Therefore, for this technique to be adopted, healthcare providers are likely to need further information, such as:
Ozawa et al. Spinal Cord Swelling After Surgery in Cervical Spondylotic Myelopathy: Relationship With Intramedullary Gd-DTPA Enhancement on MRI. Clin Spine Surg. 2018 May 31. doi: 10.1097/BSD.0000000000000664
Cho et al. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229731/
Managing energy levels
With any health condition, there is a significant impact on our energy levels. Generally, we tend to go through life doing the most we can in the shortest time. Then our health can stop us in our tracks.
Learning to manage our energy so it feels less of a rollercoaster and more predictable can be tricky. This site has a whole range of self help resources. This link is specifically to the cycles we get into which can make managing energy difficult, and ways to make changes:
Spoon Theory is another approach to managing energy:
Managing pain levels, like fatigue, links to the ideas of pacing and spoon theory. There are also specific resources about pain such as:
The pain toolkit is created by someone who experiences chronic pain. There are videos on this site and also a pdf download: https://www.paintoolkit.org/tools
The British Pain Society also has helpful information: https://www.britishpainsociety.org/
It feels like you can’t go anywhere nowadays without hearing someone talking about mindfulness. This is an approach developed from eastern Buddhist meditation techniques and applied to pain management. It was found to be so helpful it has spread throughout healthcare as a way of managing stress.
At its core is a very simple idea, which is surprisingly difficult to put into practice: “Be in the present moment.”
Most of the time we are caught up in thoughts or regrets about the past, or worries about the future, and rarely notice the present.
Have you ever driven somewhere, arriving without remembering the journey? Have you ever been reading a book without taking it in? Looking at your watch without actually seeing the time? These are all examples of being "mindless" which is the opposite of being mindful.
There are some good links about mindfulness here, and several downloads and resources to listen to:
There are many mindfulness books available. In my work I tend to use Mindfulness for Dummies, by Shamash Alidina, as it is so practical.
One very simple mindfulness practice is to go through all your senses, focusing on each one in turn. By doing this you are totally absorbing yourself in the present, even if only very briefly.
I’m also a fan of the mindful eating idea, often done with a raisin but this one uses chocolate
A great article from Brain & Life (American academy of neurology) on meditation called Inner peace.
Brain & Life
We now have our very own INSIGHT TIMER group for Cervical Myelopathy you can join by entering your details in the form belowCervical Myelopathy you can join by entering your details in the form below
Do you want to join our very own insight timer meditation group? if so please fill in your details below
How kind are you to yourself?
When you are having a tough day, do you congratulate yourself on what you manage despite that, or do you have a go at yourself for struggling?
As humans we are generally pretty rubbish at being kind to ourselves. An approach called compassion focused therapy is based on how the human brain evolved and explains why we are so tough on ourselves.
Paul Gilbert, who developed this approach, believes in sharing all the resources and information:
A summary of compassion focused therapy ideas can be found at :
There are some nice worksheets on becoming aware of your levels of criticism and compassion practices under therapist resources at: https://www.actwithcompassion.com/therapist_resources
The centre for clinical interventions is an Australian site with excellent self help workbooks for a whole range of issues including building compassion, managing panic, dealing with distress and overcoming perfectionism (a character trait many of us have but which makes pacing energy nigh on impossible so definitely worth a quick look): http://www.cci.health.wa.gov.au/resources/consumers.cfm
Most have simple questions in the first module to help you assess whether this is a specific area that might be helpful for you to explore further.
Finally, the great thing about the internet is just how many resources there are.
You may have come across many that you could share on a forum like this to help others.
There are also great Apps like Headspace which talk you through mindfulness exercises.
This is a list of Apps recommended by the NHS: https://www.getselfhelp.co.uk/links2.htm
Here is a list here of mindfulness apps:
If you feel you want further support for your mental health and ways of managing stress, a good first point of contact is your GP who can refer on to primary care therapy.
There are many parts of the UK where you can also refer yourself - the NHS website has a service finder:
Mind often offer free courses and support: https://www.mind.org.uk/
The Samaritans have useful information on their site https://www.samaritans.org/, have the phone number 116123 and you can email email@example.com (they aim to respond to email within 24 hours).
If you feel you are in crisis with your mental health and you are
having – suicidal thoughts and feelings; or thoughts about harming yourself or someone else; or you have seriously hurt yourself…
You can go to any hospital A&E department and ask for help (if you need to, call 999 and ask for an ambulance). There are specialist mental health liaison teams in hospitals who will see you quickly and be able to offer the most appropriate support
By Delphine Houlton
On completion of my first ACDF, the surgeon immediately informed my anxious husband that I would never ride a bike again.
That was in 2007 and, to be fair, I have not taken to the saddle since. After initial improvements, unfortunately many Degenerative Cervical Myelopathy (DCM) symptoms returned. Fusion had not taken place and the discs had slipped slightly.
On discharge from my second ACDF in 2008, with discs caged and this time a soft collar for six weeks, I was told not to put any strain on my neck at all. I still had balance/walking problems and numbness alongside other symptoms.
Neither my GP nor my neurologist ever contradicted the “no strain on the neck” message. Although I did learn that if I had MS I would have been immediately offered physiotherapy and hydrotherapy.
So, I dutifully did not put strain on my neck for more than eight years – my symptoms worsened as I gained weight, and felt rubbish, in an exercise desert.
After all, logically, the gym was out of the question – I would have fallen over if I had gone on the treadmill thanks to the balance problems. Even in the shopping centre my legs seized up after a three-minute slow and painful walk. Furthermore, my favourites in a previous life, rowing machines and swimming certainly put strain on the neck, as did all weight-training equipment.
Giving up work and becoming more housebound, in total frustration, I found a private physiotherapist and explained the problems. She was knowledgeable and caring. I worked hard to strengthen my core muscles, improve my balance and more. However, progress was slow and, to be honest, the exercises boring in the longer term. However, she had opened a window of possibility.
The goal, I was told, was to revive muscle memory. Taking advantage of the ease of movement in the warm water, I was reminding all my muscles how they should be working in a whole range of manoeuvres I found impossible out of the water.
My initial six sessions gave me the confidence, and the ability, to tackle so much more out of the water too.
Additional sessions have built up my strength and confidence even further.
I can now tackle many tasks in the garden, go for a short walk on uneven ground in the countryside, and walk up and down stairs without too much discomfort or fear of falling. I can even bend enough to put on boots, socks and tights again!
Of course, there are still not-so-good days when I need to think harder about where all my limbs are and how to move them. However, the confidence I have regained through hydrotherapy keeps me going and keen to take on more physical challenges at every possible opportunity.
Unsurprisingly, my mood too has greatly improved – I see a much brighter future ahead rather than the gloom and frustration of a continuing decline in physical abilities and increasingly limited lifestyle.
The transformation hydrotherapy has brought to my exercise desert is clearly anecdotal evidence. Proper research is needed into the benefits of hydrotherapy for people with DCM.
If hydrotherapy can be shown to improve outcomes, and relieve low mood associated with limited lifestyles, then we must push for the option of hydrotherapy to be incorporated into all DCM post-operative treatment programmes. It also possibly has the potential to help relieve pre-operative problems too.
by A Badran
Our ambition therefore was to look at the medical literature to see if there was any suggestion it could be of benefit to patients with myelopathy.
How did we go about this?
We performed something called a systematic review and this has recently been published in the journal of Clinical Rehabilitation. (1) This is a research technique which rigorously screens databases of medical literatures. Typically this is done in three stages: Firstly, a search strategy (string of relevant words) is put together. This is then applied to medical literature databases and the results of the search are manually screened, initially by their title and summaries. Any articles considered potentially relevant and then read in full to evaluate their relevance to the research question.
What did we find?
We found only one study commenting on the effects of physiotherapy after surgery for DCM. This is a small retrospective study of 21 patients with DCM that underwent surgery and then rehabilitation. However it was a poor quality study, and spontaneous recovery after surgery could not be distinguished from the effects of physiotherapy specifically. Although the study concluded that rehabilitation improved functional status, the small study size and its design make this conclusions very tentative.
Therefore, unfortunately, we identified that the effect of postoperative physiotherapy in DCM has been poorly studied and we could not make any recommendations about whether it should be routinely provided. This does not mean that physiotherapy is harmful or should not be provided after surgery for degenerative cervical myelopathy but simply more investigation is required.
Pleasingly there are now two registered randomised controlled trials, one in Taiwan and another in Canada, which will hopefully shed light on the effects of postoperative rehabilitation in DCM.
1. Badran et al. Is there a role for postoperative physiotherapy in degenerative cervical myelopathy? A systematic review. Clinical Rehabilitation. April 2018.
Why is ASCC relevant to Degenerative Cervical Myelopathy?
Asymptomatic spinal cord compression (ASCC) is very common; studies of healthy volunteers has identified between 8 and 59 in every 100 patients who underwent a cervical MRI had it!  These are the same compression features seen in DCM, however less that 1 in a hundred patients from these studies had any symptoms of myelopathy…. Hence the term ASCC (as opposed to DCM, which is defined by the symptoms of the condition, such as pain and weakness).
However, we know from other studies that some people with ASCC go onto develop DCM over time and this has led to the suggestion that ASCC actually represents the earliest stages of DCM. In order to further evaluate this, researchers from North America have been using new MRI imaging techniques to better understand asymptomatic cord compression and to see whether the compression is affecting the spinal cord.
What was the aim of the study?
The study, undertaken at the University of Toronto had two primary aims:
1)Can ASCC be automatically diagnosed by using computer analysis of MRI images?
2)Can damage to the spinal cord be visualised using new MRI techniques in ASCC?
How did they measure subclinical damage and cord compression?
The group recruited 40 individuals to the study, 20 of which has ASCC and 20 had no evidence of cord compression.
Aim Number 1
The performance of a computer programme to diagnose cord compression was compared to a group of experts and found to be just as good.
Aim Number 2:
The group then compared people with and without ASCC using a number of new techniques to look at the structure within the spinal cord, these include the following
The researchers found that some of these new imaging techniques were able to detect changes within the ASCC group that are also seen in DCM; specifically, FA, MTR and T2*WI WM/GM. When compared to uncompressed individuals, a combined score looking at a combination of parameters was very accurate at spotting tissue injury. This indicated that there is a degree of tissue damage before symptoms in ASCC, and that this perhaps represents the early stage of degeneration that progresses into degenerative cervical myelopathy.
What to make of this?
This study is informative to clinicians, as it reflects a way to diagnose ASCC early on before significant damage has been done to induce symptoms. The success of the computer diagnosis also means ‘expertise’ can be transferred into any hospital setting. This is exciting, as we know that if we could detect DCM earlier, and offer treatment sooner, patients would make a better recovery.
The finding that ASCC causes tissue damage also may make us question our definition of myelopathy. Currently, symptoms are the definitive characteristic of myelopathy, but as advances in technology allow us to detect spinal cord damage in the absence of symptoms, this may change. The symptoms of myelopathy may reflect a later stage of damage that occurs after what we can now see using MRI.
Furthermore, the findings of similar tissue injury in ASCC to DCM indicated a possible definitive link between the two disease states. The researchers compare the two as being similar to “pre-diabetes” and “diabetes” (a scenario where people who are struggling to handle their blood sugars are identified even earlier, with some able to make changes to prevent the onset of diabetes). Perhaps what we are seeing here is a “pre-DCM” state. This still requires more work to be confirmed. We look forward to following the research story further!
Myelopathy needs you!
One of the most perplexing things about DCM is the role of spinal cord compression in the disease. It easy to think that the picture is a simple one: as the spine degenerates (joints wearing out, ligaments hardening and bones shifting position) the spinal cord gradually becomes compressed. This compression damages the spinal cord, kills off nerves cells and leads to the development of myelopathy. However, as we’ve mentioned, many people can have compression of the spinal cord but have no sign of myelopathy, while others can have extremely severe symptoms from the same amount of compression. It seems that we need to look at subtler imaging signs to better differentiate between people with and without DCM.
A group of researchers at Wenzhou Medical University in China, led by Wu Shiyang , thought that one such factor could be reduced spinal blood flow. They reasoned that the same degenerative changes that compress the spinal cord in older people could also compress the blood vessels that supply it, the so called ‘spinal arteries’ (Figure 1). If these arteries became compressed there would be less oxygen reaching the cord, leading to death of nerve cells and inflammation of the surrounding areas. This damage to the spinal cord could lead to the symptoms of myelopathy.
What did this study involve?
1. The difference in blood flow between pre-surgery DCM patients and healthy patients
2. The difference in blood flow between pre-surgery and post-surgery DCM patients
3. Any link between change in JOA score (disability) and change in blood flow after surgery
What did this study show?
1. Blood flow through the anterior spinal artery is significantly lower in pre-surgery DCM patients than healthy patients
2. Surgery leads to a significant increase in spinal artery blood flow in DCM patients
3. Patients who had bigger improvements in blood flow after surgery had greater recovery in JOA score (i.e. were less disabled) 6 months later
What might these results mean for the future?
1. They could help us better understand the underlying processes which damage the spinal cord in DCM, which in turn would help us develop new treatments. These results could even help explain why spinal cord compression on imaging doesn't always cause DCM – perhaps compression of the spinal arteries is also required for symptoms to develop.
2. They could help us diagnose myelopathy earlier. Reduced spinal blood flow could now be considered a sign of DCM, which we can combine with our existing diagnostic makers (MRI scans, neck pain, disability etc). The earlier we diagnose myelopathy the sooner we can operate and the less severe lasting disability will be. Remember: time is spine.
3. They could help us assesses how successful surgery has been and predict how much recovery we can expect. A big improvement in blood flow suggests that recovery will be better. This clarity can help us plan your future care and helps you know what to expect.
4. They could help us compare treatments to see which is best. Surgeries that produce the bigger increases in blood flow may lead to better recovery than surgeries which produce smaller improvements in blood flow. Shiyang’s group has already planned studies to see if DECT can be used to compare outcomes of anterior vs posterior decompression operations.
What are the limitations of this study?
2. Zhang, Z. & Wang, H. CT angiography of anterior spinal artery in cervical spondylotic myelopathy. Eur. Spine J. 22, 2515–9 (2013).
Firstly you need to go the Social Security Administration page. You can apply online, or have the forms sent to your home.
Social Security Benefits (SSI)
As far as Social Security benefits, SSI is a set disability amount which is awarded for those who have not worked enough years or haven't paid enough social security tax into the system. For example, the maximum amount right now is $750/monthly. SSDI benefits are disability benefits awarded based on wages over the years and paid into Social Security. You could range anywhere from a couple hundred to a couple thousand dollars monthly. Both benefits are issued through the social security administration.
You need to be deemed disabled for an expected period of at least 12 months. For disability, benefits, especially SSI, most applicants are denied the first time. That's typically when one obtains a lawyer to handle the appeal. It just seems to be common practice. It can take months to finally get approved. Obviously depending on the level of severity, but it can take anywhere from 6 months to a little over a year.
As far as medical coverage, there are programs through public welfare and types or medical coverage available associated specifically with disability. One is directly related to SSI recipients, one is disability clients with no income/awaiting benefits, there is one for those who work but fall under certain income limits, one for those receiving SSDI who fall under certain income limits, and for those who receive SSDI and receive Medicare part B through social security - if they make too much to qualify for the welfare medicare, there's another income limit to see if welfare will at least pay their Medicare B monthly premium amount, so they would at least have that premium amount back in their pockets in the SSDI check. All of those types of medical are applied for through Dept. Of Human Services /formerly Dept. Of Public welfare.
If anyone in the US is looking for cash assistance while awaiting disability, they can also apply through Dept Human Services. For example, the guidelines to qualify for cash assistance benefits is that you have to have care/control of a minor child. So a parent/parents with custody. The amounts are very low though, right now, if a parent of 2 applies for cash assistance, and has zero income, the maximum grant amount monthly for that 3 person household is only $403. Better than nothing but clearly doesn't touch the bills. There are job search requirements with this program. But if you are disabled, you have a form completed by your physician and are waived from those requirements. We also have what is called a DAP- Disability Advocate Program, and they can help individuals seeking SSI throughout the process.
Each state has different programs to help the disabled offset costs.
Some states have fuel assistance. Every year , a household gets a certain amount of money paid to their heat supplier for heating through the winter.
Most disabled people , if qualified can get SNAP, which is the food stamp program.
If you've got young children under the age of 5 , there is the WIC program which delivers food to low income mothers.
If you are disabled, and get SSDI, your children get a small disability check also. That lasts until they are 18, or have graduated from high school.
Most states have food banks, if you need food please use them.
Churches also have programs for food, the elderly, and the disabled. Ask your pastor for any information or programs that could help your family.
Disability Benefit Centre
Information kindly collated and presented by Margot Miller and Melissa Rodriguez
If you have any relevant information on the benefit system for the USA and would like to see it featured please get in touch: firstname.lastname@example.org
All this information is now available at www.myelopathy.org/disability-benefit-advice-usa.html
Our Facebook Myelopathy Support group, founded by Iwan Sadler, now has more than 1,000 members worldwide.
A great success story which is set to grow as awareness of Degenerative Cervical Myelopathy (DCM) increases.
There is little doubt that social media is revolutionizing health care. A US study by Pricewaterhouse Cooper in 2012 showed that one third of US consumers use social space as a natural habitat for health discussions. Meanwhile a 2010 report by the Pew Internet and American Life Project showed one half of e-patients living with chronic diseases take advantage of user generated information.
Using this research and more, Pius Boachie writing for http://www.adweek.com/digital/ demonstrates the importance of Facebook groups for people with health issues sharing experiences, offering support and raising awareness and funds.
Social media has also given patients opportunities to vent their frustrations and anger as well as following up issues keeping healthcare providers on their toes.
But it is not just of benefit to the patients. Pius Boachie claims 88% of doctors use social media to research pharmaceutical, biotech and medical devices, and 60% of doctors say social media improves the quality of care delivered to patients.
However, at Myelopathy Support we are facing a challenge and one that not only Iwan has noticed. Our Facebook group has attracted many more women than men. In fact, 76.7% of Myelopathy Support members are women and just 23.2% men!
The specialists tell us that DCM does not discriminate between the sexes, so what is going on?
According to research by Statista, women have been leading the way on the major social media platforms, such as Facebook, for a long time but the gap is narrowing. Now the USA has 230 million Facebook users of which 52% are women and 48% are men.
So, men are aware of Facebook and interacting but there is a possibility they are using it differently. At least this is an argument presented in www.socialmediatoday.com in 2016.
The authors say research reveals men are more likely to use social media to seek information or new relationships while women use platforms such as Facebook to connect with people and nurture existing relationships.
Women are more likely to share personal issues while men prefer more abstract topics. On a more negative note, men were much more commonly trolling on social media or engaging in aggressive and even abusive language. In conclusion, they accept that men and women communicate differently.
This sort of argument can be compelling along the lines of the popular Men are from Mars, Women are from Venus theses. I’m not a huge fan not least because I favour nurture over nature and see most styles of communications as culturally constructed with culture very clearly an ongoing process – a verb and not a noun.
Irrespective of my preferences, we do face the challenge of attracting more men to join and to benefit from the information, support and expertise available at Myelopathy Support on Facebook.
Should we be doing more on YouTube (54% male users) who spend, on average, twice as much time as women do on the site per week? Should we signpost the vast amount of detailed information available at Myelopathy Support more clearly? Should we run an invite-a-man initiative or offer a prize to the 500th man to sign up?
All suggestions gratefully received! Email: email@example.com
Can you help researchers from the University of Nottingham?
I plan to undertake a qualitative project interviewing approximately 8-16 participants to find out whether they have returned to at least 2 hours of exercise a day following the surgery. I would like to know whether they developed problems such as neck pain or pain or loss of function of the arms and legs with exercise.
Being a GP, I hope I can interpret the interviews and help people who require advice on getting fit after surgery.
Please have a look at my advert and get in touch if you would like to be involved.
Dr Teena Fernandez
MBBS MRCGP DFFP DRCOG BMEDSCI PGCE
Why does this matter? A word from the director
Worried about participating in research?
Cervical spondylosis, more than a pain in the neck?
For some migraines is just another word for headache, but in medicine it refers to a specific type of headache characterised by severe head pain that can last from 2-72 hours, are a common disorder and can be incapacitating to people who suffer them. Migraines are common, with estimates suggesting up to one billion people are affected worldwide. Various triggers may cause migraines, causing a sequence of events that lead to head pain. It has been suggested that cervical spondylosis, the degeneration of the bones of the neck, may initiate migraines, but little research has been done on the topic.
How was it done?
Do you suffer from headaches or pain and have CSM?
Researchers from the University of Cambridge what to hear about your experience
What were the results?
How could this happen?
What does this mean for Myelopathy sufferers?
In the meantime, some small things that can minimize your risk of migraine include: remain well hydrated, reducing your caffeine intake (although some people find caffeine helpful), as well as ensuring a regular sleeping habit.
A message from the director
As you are only too aware, Myelopathy is a condition which faces a number of significant challenges including lifelong disability, widespread misunderstanding and under-recognition, and a lack of clear information or support. Myelopathy.org was founded to address these issues and become a rallying point for change.
We see research as an important part of delivering change and support projects that can advance our understanding. As the largest ever Myelopathy community, your shared experiences have a lot to offer researchers, and therefore health surveys have been a prominent part of our research arm. So far, more than 2000 people have shared their experiences, making these some of the largest ever studies in Myelopathy. That data is still being processed, and we look forward to seeing the results soon, but this in itself is a testament to what we can achieve together.
As an organisation we recognise the power of this community and are committed to its responsible management. In this respect, all research associations and projects have been and are expected to meet our ethical standards. This includes adhering to our code of conduct, providing appropriate regulatory approval and practicing safe management of personal data. All proposed surveys are first piloted and approved internally.
Looking through our research section today, I can see that this oversight is not as explicit as it should be, and we will be introducing clearer documentation to correct this.
We are a very young organisation, developing and learning as we go along but in a short time we have made great in roads; I remember when we first launched, canine myelopathy was the prominent feature of google search results, but now our myelopathy has come to the forefront.
There is still a long way to go, but it will be together that we can drive change and not as individuals. The internet has provided a platform for us to come together, but we must remember that it can also have the potential to divide us: both as an organisation and as individual members we all must act responsibly. In that regard, if you feel any of our actions or the actions of our members questionable, please get in touch directly.
Thank you for your ongoing support.
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