Investigation of Subclinical Markers of Multiple Sclerosis

Study Overview
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Brief Summary
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Transcranial magnetic stimulation (TMS) studies reported consistent and substantial impairments in the central nervous system (CNS) in multiple sclerosis (MS). Studies of peripheral nervous system (PNS) function comprising electromyoneurography (EMNG) reported impairments of the PNS in MS that were less pronounced and inconsistent. Neurophysiological studies are generally small and cross-sectional and with the poor grouping of MS patients according to MS type. The objective of the study is to investigate clinical, neurophysiological, and immunological markers in relapsing-remitting MS patients, and in patients with relapsing-remitting MS treated with immunomodulation. The results of the study may contribute to a better understanding of the pathophysiology of multiple sclerosis and can provide guidance in the diagnosis and treatment of patients with relapsing-remitting MS.

Detailed Description
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The following techniques will be applied: Neurophysiological testing will be performed with navigated transcranial magnetic stimulation (nTMS) incorporating an individual MRI of each subject's brain performed on a 1,5 MRI scanner using a series of neuropsychological protocols. Mapping of the primary motor cortex for upper and lower extremity muscles with a recording of motor evoked potentials (MEP) will be performed. Electromyoneurography (EMNG) assessment of lower and upper extremities for motor and sensory nerves; Neuropsychological assessment will include the general questionnaire and battery of cognitive and psychological tests; Immunoassays on blood samples include determination of different markers on monocytes and lymphocytes using flow cytometry, as well as determination of CD163 in serum samples using ELISA. Clinical examinations include neurological, biochemical, neuroradiological, and neuropsychological testing.

Official Title
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Investigation of Subclinical Markers of Multiple Sclerosis

Conditions
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Multiple Sclerosis, Relapsing Remitting Multiple Sclerosis

Intervention / Treatment
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* Diagnostic Test: 1. Clinical testing; 2. Neurophysiological examination (TMS, EMNG); 3. Psychomotor examination; 4. Neuropsychological evaluation; 5. Flow cytometry; 6. ELISA


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Subjects with a documented diagnosis of relapsing-remitting MS according to the Mc Donald criteria (2005) and with EDSS achievement of 0-3.5 according to the modified Kurtzke's EDSS (Expanded disability status scale) for the assessment of neurological function and incapacity of patients with multiple sclerosis Exclusion Criteria: Patients with metals in the body (e.g. pacemaker, dentures) Patients with new pregnancies (verbally confirmed) Patients with new head trauma Subjects unwilling to sign a consent or follow study procedures

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 65 Years

Sexes Eligible for Study
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All

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Relapsing-remmitting MS group treated with corticosteroids<br>Clinical testing Neurophysiological examination (TMS, EMNG) Psychomotor examination Neuropsychological evaluation Flow cytometry ELISA | Diagnostic Test: 1. Clinical testing; 2. Neurophysiological examination (TMS, EMNG); 3. Psychomotor examination; 4. Neuropsychological evaluation; 5. Flow cytometry; 6. ELISA<br>* All groups will not have the same intervention. Interventions are listed and numbered for each group.<br>|
| Relapsing-remmitting MS group treated with immunomodulation<br>1. Clinical testing 2. Neurophysiological examination (TMS, EMNG) 4. Neuropsychological evaluation 5. Flow cytometry | Diagnostic Test: 1. Clinical testing; 2. Neurophysiological examination (TMS, EMNG); 3. Psychomotor examination; 4. Neuropsychological evaluation; 5. Flow cytometry; 6. ELISA<br>* All groups will not have the same intervention. Interventions are listed and numbered for each group.<br>|
| Healthy control group<br>5. Flow cytometry | Diagnostic Test: 1. Clinical testing; 2. Neurophysiological examination (TMS, EMNG); 3. Psychomotor examination; 4. Neuropsychological evaluation; 5. Flow cytometry; 6. ELISA<br>* All groups will not have the same intervention. Interventions are listed and numbered for each group.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| TMS assessment of resting motor threshold (RMT) change | Neurophysiologic measure of RMT (expressed in percentage of maximal stimulator output) will be evaluated with navigated TMS over the primary motor cortex: in relapsing-remitting MS receiving corticosteroid treatment patients in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). relapsing-remitting MS receiving immunomodulation treatment patients at baseline | RMT before and 5 weeks after steroid intake in relapsing-remitting MS patients. RMT in relapsing-remitting MS group on immunomodulation. | 
| TMS assessment of motor evoked potentials (MEP) changes from upper and lower extremity muscles | The neurophysiologic measure of MEP (amplitude expressed in microvolts and latency expressed in milliseconds) will be evaluated with navigated TMS over the primary motor cortex for upper and lower extremity muscles: in relapsing-remitting MS receiving corticosteroid treatment patients in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). relapsing-remitting MS receiving immunomodulation treatment patients at baseline | MEP (amplitude and latency) before and 5 weeks after steroid intake in relapsing-remitting MS patients. MEP (amplitude and latency) in relapsing-remitting MS group on immunomodulation. | 
| TMS assessment of cortical silent period (CSP) change | The neurophysiologic measure of CSP duration (expressed in milliseconds) will be evaluated with navigated TMS over the primary motor cortex in relapsing-remitting MS patients in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). | Baseline CSP, CSP change at 5 weeks taking the steroids | 
| TMS assessment of short afferent latency inhibition (SAI) change | The neurophysiologic measure of SAI phenomena (expressed in milliseconds) will be evaluated with navigated TMS over the primary motor cortex with peripheral electrical stimulation over the median nerve at different interstimulus intervals (20-28 ms) in relapsing-remitting MS patients in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). | Baseline SAI, SAI change at 5 weeks after taking the steroids. | 
| EMNG assessment of distal motor latency (DML) and sensory nerve action potential latency (SNAP) change | EMNG measures of DML and SNAP latency (expressed in milliseconds) of upper and lower extremities will be evaluated in relapsing-remitting MS patients receiving corticosteroid treatment in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). EMNG measures of DML and SNAP latency (expressed in milliseconds) of upper and lower extremities will be evaluated in relapsing-remitting MS receiving immunomodulation treatment patients at baseline. | DML and SNAP latency before and 5 weeks after steroid intake in relapsing-remitting MS patients. DML and SNAP latency in relapsing-remitting MS group on immunomodulation. | 
| EMNG assessment of muscle action potential amplitude (CMAP) and sensory nerve action potential amplitude (SNAP) change | EMNG measures of CMAP and SNAP amplitude (expressed in millivolts) of upper and lower extremities will be evaluated in relapsing-remitting MS patients receiving corticosteroid treatment in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). EMNG measures of CMAP and SNAP amplitude (expressed in millivolts) of upper and lower extremities will be evaluated in relapsing-remitting MS patients receiving immunomodulation treatment at baseline. | CMAP and SNAP amplitude before and 5 weeks after steroid intake in relapsing-remitting MS patients. CMAP and SNAP amplitude in relapsing-remitting MS group on immunomodulation. | 
| EMNG assessment of motor and sensory conduction velocity (CV) change | EMNG measures of CV (expressed in meters per second) of motor and sensory nerves of upper and lower extremities will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). EMNG measures of CV (expressed in meters per second) of motor and sensory nerves of upper and lower extremities will be evaluated in relapsing-remitting MS patients treated with immunomodulation treatment at baseline. | CV before and 5 weeks after steroid intake in relapsing-remitting MS patients. CV in relapsing-remitting MS group on immunomodulation. | 
| EMNG assessment of F-wave change | -EMNG measures of F-wave (expressed in milliseconds) for motor nerves of upper and lower extremities will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). --EMNG measures of F-wave (expressed in milliseconds) for motor nerves of upper and lower extremities will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. | F-wave before and 5 weeks after steroid intake in relapsing-remitting MS patients. F-wave in relapsing-remitting MS group on immunomodulation. | 
| CD 14 expression on peripheral blood monocytes change | CD 14 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 14 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline.The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 14 expression on monocytes will be evaluated in the healthy control group.The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. | CD 14 before and 5 weeks after steroid intake in relapsing-remitting MS patients. CD14 in relapsing-remitting MS group on immunomodulation and healthy control group. | 
| CD 16 expression on peripheral blood monocytes change | CD 16 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 16 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 16 expression on monocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. | CD 16 before and 5 weeks after steroid intake in relapsing-remitting MS patients. CD16 in relapsing-remitting MS group on immunomodulation and healthy control group. | 
| CD 40 expression on peripheral blood monocytes change | CD 40 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, and 5 weeks after taking the steroids). The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 40 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 40 expression on monocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. | CD 40 before and 5 weeks after steroid intake in relapsing-remitting MS patients. CD 40 in relapsing-remitting MS group on immunomodulation and healthy control group. | 
| CD 192 expression on peripheral blood monocytes change | CD 192 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with corticosteroids in 2 phases (before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids). The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 192 expression on monocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes. CD 192 expression on monocytes will be evaluated in a healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive monocytes | CD 192 before and 5 weeks after steroid intake in relapsing-remitting MS patients. CD 192 in relapsing-remitting MS group on immunomodulation and healthy control group. | 
| Change of CD 163 levels in blood serum samples | CD 163 levels in serum will be evaluated in relapsing-remitting MS patients in 2 phases (before the intake of steroids, 5 weeks after taking the steroids). CD 163 levels will be measured with ELISA assay (expressed in micro mols per litre). | CD 163 measured before and 5 weeks after taking the steroids. | 
| CD 4 expression on lymphocytes | CD 4 expression on lymphocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. CD 4 expression on lymphocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. | Determination of CD 4 at the beginning of study (study entry) in relapsing-remitting MS patients treated with immunomodulation and in healthy control group. | 
| CD 25 expression on lymphocytes | CD 25 expression on lymphocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. CD 25 expression on lymphocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. | Determination of CD 25 at the beginning of study (study entry) in relapsing-remitting MS patients treated with immunomodulation and in healthy control group. | 
| CTLA-4 expression on lymphocytes | CTLA-4 expression on lymphocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. CTLA-4 expression on lymphocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. | Determination of CTLA-4 at the beginning of study (study entry) in relapsing-remitting MS patients treated with immunomodulation and in healthy control group. | 
| FOXP3 expression on lymphocytes | FOXP3 expression on lymphocytes will be evaluated in relapsing-remitting MS patients treated with immunomodulation at baseline. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. FOXP3 expression on lymphocytes will be evaluated in the healthy control group. The expression will be measured as the median of fluorescence distribution acquired with flow cytometry. The expression will also be quantified as the percentage of positive lymphocytes. | Determination of FOXP3 at the beginning of study (study entry) in relapsing-remitting MS patients treated with immunomodulation and in healthy control group. | 
| Hand dominance assessment with Edinburgh Handedness Inventory test. | The Edinburgh Handedness Inventory is a well known short questionnaire for determining objectively whether one is left , right handed, or ambidekster. The subjects determines whether he/she is using right or left hand for specific activities (ten activities). The total checks are given for right and left hand, than cumulative sume is given (total checks from right and left hand), difference between total checks for right minus left hand. Final result is the difference result subtracted from cumulative result x 100. | Baseline measurement for single subject. The results for all subjects can be provided an average of 1 year of study duration. | 
| Cognitive assessment change applying Letter Digit Substitution Test (LDST). | Relapsing-remitting MS patients treated with corticosteroids will be tested with LDST before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. LDST is interpreted as the number of correct responses in 60 seconds. Relapsing-remitting MS patients treated with immunomodulation therapy will be tested with LDST at baseline. | Baseline LDST, and LDST change at 5 weeks and 6 months after taking the steroids. | 
| Cognitive assessment change applying Montreal Cognitive Assessment (MoCA). | Relapsing-remitting MS patients will be tested with MoCA before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. MoCA is interpreted as the number of points (30 is maximal). | Baseline MoCA, and MoCA change at 5 weeks and 6 months after taking the steroids. | 
| Psychological assessment change applying Multiple Sclerosis Impact Scale (MSIS-29). | Relapsing-remitting MS patients treated with corticosteroids will be tested with MSIS before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. The total score is formed as the sum of the rounded answers to the two subscales (physical and psychological scale). Relapsing-remitting MS patients treated with immunomodulation will be tested with MSIS at baseline. The total score is formed as the sum of the rounded answers to the two subscales (physical and psychological scale). | Baseline MSIS-29, and MSIS-29 change at 5 weeks and 6 months after taking the steroids. | 
| Psychological assessment change applying Depression, Anxiety, Stress (DASS-21) scale. | Relapsing-remitting MS patients treated with corticosteroids will be tested with DASS-21 before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. Relapsing-remitting MS patients treated with immunomodulation will be tested with DASS-21 at baseline. DASS-21 contains three scales for measuring emotional states of depression, anxiety and stress. Each scale contains 7 statements. The result on the depression, anxiety and stress scales is the sum of the rounded answers to specific statements. | Baseline DASS-21, and DASS-21 change at 5 weeks and 6 months after taking the steroids. | 
| Psychological assessment change applying Fatigue Severity Scale (FSS). | -Relapsing-remitting MS patients treated with corticosteroids will be tested with FSS before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. --Relapsing-remitting MS patients treated with immunomodulation will be tested with FSS at baseline. The subject is asked to read each statement and circle a number from 1 to 7, depending on how appropriate they felt the statement applied to them over the preceding week. A low value indicates that the statement is not very appropriate whereas a high value indicates agreement.The scoring is done by calculating the average response to the questions (adding up all the answers and dividing by nine). | Baseline FSS, and FSS change at 5 weeks and 6 months after taking the steroids. | 
| Psychological assessment change applying Pain rating scale. | Relapsing-remitting MS patients will be tested with numerical Pain Rating Scale before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. The result is interpreted as the total sum of points. The greater the results the more pain is detected. | Baseline Pain rating, and Pain rating change at 5 weeks and 6 months after taking the steroids. | 
| Psychomotor assessment of hand grip change applying SAEHAN Squeeze Dynamometer. | Relapsing-remitting MS patients will be tested with SAEHAN Squeeze Dynamometer before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. Six measurement results are recorded for each subject - three for the grip with the dominant hand and three for the grip with the non-dominant hand. The final result is the mean of the three measurements for each arm expressed in kilograms. | Baseline hand grip, and hand grip change at 5 weeks and 6 months after taking the steroids. | 
| Psychomotor assessment change of extremity muscles applying Lafayette Manual Muscle Tester Dynamometer. | Relapsing-remitting MS patients will be tested with Lafayette Manual Muscle Tester Dynamometer before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. Muscle strength measured by Lafayette Manual Muscle Tester is recorded in kilograms and normalized to body-mass index (BMI). Handheld dynamometry will be used to measure ankle dorsiflexion; knee, flexion and extension; hip flexion, extension, abduction, and adduction; and trunk lateral flexion. | Baseline lower and upper extremity muscle strength, and muscle strength change at 5 weeks and 6 months after taking the steroids. | 
| Psychomotor assessment change applying Lafayette O'Conner Finger Dexterity Test. | Relapsing-remitting MS patients will be tested with O'Conner Finger Dexterity Test before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. The O'Connor Finger Dexterity Test requires hand placement of 3 pins per hole. Result (seconds) = time required to complete the first part of the test + (1.1 x time required to complete the second part of the test) / 2 | Baseline O'Conner, and O'Conner change at 5 weeks and 6 months after taking the steroids. | 
| Barthel Index for Activities of Daily Living (ADL) change. | Relapsing-remitting MS patients will be tested with Barthel Index for Activities of Daily Living (ADL) before the intake of steroids, 5 weeks after taking the steroids and 6 months after taking the steroids. The examiner is rank the patient's independence in the following areas:feeding, bathing, grooming, dressing, bowel control, bladder control, toilet use, transfers (bed to chair and back), mobility on level surfaces, and stairs. * 0 - 20 = complete dependence; 21 - 60 = severe addiction; 61 - 90 = moderate dependence | Baseline activities of daily living, and change in activities of daily living at 5 weeks and 6 months after taking the steroids. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| -Detection of potential predictors (neurophysiological, neuropsychological, clinical neurological, clinical biochemical, and MRI measures) of medication treatment of relapsing-remitting MS. | Correlation and regression methods will be used to examine the following data: neurophysiological data acquired with TMS (RMT; MEP; CSP; SAI); neurophysiological data acquired with EMNG (DML and SNAP latency; CMAP and SNAP amplitude; motor and sensory CV; F-wave); immunological data (expression profile of CD40, CD192, CD14, CD16 on monocytes and CD25, CTLA-4 and FOXP3 on lymphocytes; expression of CD163 in serum); neuropsychological data; Edinburgh Handedness Inventory test; Pain rating scale; Barthel Index for Activities of Daily Living (ADL); FSS; LDST; MoCA; MSIS-29; DASS-21; O'Conner Finger Dexterity Test; muscle strength - hand grip and upper and lower extremity muscles with a dynamometer clinical: EDSS,T25-FW; MRI; biochemical (complete blood count, differential blood count, AST, ALT, GGT, blood sugar test, creatinine, urine, B12, Na, K, Cl, folic acid, neurotrophic virus in serum and liquor, oligoclonal band) | The complete data results will be provided at the end of the study. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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multiple sclerosis, relapsing remitting, TMS, Cytometry, ELISA, corticosteroids, immunomodulation