Nerve Disease ALS and

Gradual Loss of Muscle

Function
Nerve Disease ALS and
Gradual Loss of Muscle
Function
Amyotrophic Lateral Sclerosis

Mary E. Miller
Nerve Disease ALS and Gradual Loss of Muscle Function: Amyotrophic
Lateral Sclerosis
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 Abstract
Amyotrophic lateral sclerosis, ALS, is a common form of motor n ­ euron
disease that involves a loss of function in upper and lower motor n
­ eurons.
ALS causes a progressive loss of muscle function that frequently i­nitiates
in the limbs, called limb-onset ALS, or initiates in facial muscles, called
bulbar-onset ALS. This book describes the current understanding of
ALS symptoms, diagnosis, causes, and treatments. Initial symptoms
vary in type of muscle dysfunction, intensity of symptoms, and speed
of ­disease progression. Diagnosis requires loss of function in both upper
and lower motor neurons for limb- and bulbar-onset ALS, distinguishing­
ALS from other neuromuscular diseases. Although no cause or initial
trigger has been determined for ALS, eventually both limb and bulbar
muscles will show dysfunction as the disease progresses. In later stages of
the ­disease, muscle dysfunction typically leads to respiratory failure and
death. Management of neurotransmitter levels in patients can ­prolong
life by months, but no cure exits for the disease. Other treatments
exist that can help patients manage muscle weakness or spasms as the
­disease ­progresses. The book concludes by considering future detection,
­treatment, and diagnostic approaches with the goal of preventing disease
­initiation or progression.

Keywords
amyotrophic lateral sclerosis (ALS), Lou Gehrig’s disease, motor neuron
disease, neuromuscular junction, limb-onset ALS, bulbar-onset ALS,
muscle weakness
 Contents
Introduction...........................................................................................ix
Chapter 1  Symptoms and Diagnosis..................................................1
Chapter 2  Causes and Contributing Factors......................................7
Chapter 3  Treatment and Therapy...................................................17
Chapter 4  Future Prospects..............................................................21
Conclusion............................................................................................25
Bibliography..........................................................................................27
Glossary................................................................................................31
About the Author...................................................................................35
Index....................................................................................................37
 Introduction
Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s
disease, is characterized by a loss of muscle function that is progressive,­
or worsens over time. It is most commonly observed in white males
­between the ages of 40 to 60; but occurs at all ages in men and women,
and crosses all cultural and socioeconomic boundaries. ALS causes a loss
of muscle function due to defects in motor neurons and frequently leads
to death within 2 to 5 years after the initial diagnosis. The cause of ALS
is unclear and there is no known cure. ALS is not a nationally notifiable
condition, meaning that cases of ALS are not required to be reported to
the government and reporting systems are governed by local laws. For
example, in 2007, the state of Massachusetts mandated that ALS cases be
reported, and was the only state with this mandate as of 2015. For this
reason, specific statistics describing incidence rates in the United States
are lacking. To better gauge ALS disease occurrence, a voluntary national
health registry in the United States was created in 2009 to collect data
on ALS. Based on those cases that are reported to the ALS national health
registry, prevalence of ALS occurs at 3.9 per 100,000 individuals in the
United States. Other estimates approximate a total of 30,000 patients
with ALS in the United States.
ALS is very costly, particularly in the later stages of the disease where
muscle function is severely impaired. The bulk of cost in late stages of
the disease will include in-home caregivers, ventilation equipment,
and hospital stays. Even in early stages expenses are high, with the only
FDA-approved treatment at times costing up to $12,000 per year. Esti-
mates suggest that over a 10-year period, the cost of diagnosis, treatment,
and care of an ALS patient in the United States is about $1.5 million.
National estimates place the total cost of ALS in the United States at
$433 million per year, making it comparable to other debilitating
diseases such as Parkinson’s and multiple sclerosis. As patients lose the
ability to produce income, family members often become caregivers
which amplifies the financial and emotional toll of the disease. ALS is
x INTRODUCTION

a stressful experience for patients and the patients’ caregivers due to the
emotional, physical, and financial repercussions.

What is ALS?
In an ALS patient, muscle function decreases due to degeneration and
loss of cells in the brain and spinal cord of the nervous system that are
important for muscle movement. Cells are the fundamental living unit
in our bodies—collectively they form the complex tissues and organs that
are needed for bodies to function. In the nervous system, there are several
types of cells required for proper neural function that are important in
the control of muscle movement. These cell types include the neurons
which transmit information in the nervous system. There also exist glial
cells which participate in neuronal communication and provide support
to neurons by supplying extracellular structures, nutrients, and repair.
The types of neurons important for muscle movement that are defec-
tive in ALS patients are called motor neurons, so ALS is classified as a
motor neuron disease (MND). ALS is the most common motor neuron
disease in the United States and frequently the term MND and ALS are
used interchangeable. Motor neurons are responsible for muscle control
such as hand movement, walking, talking, swallowing, and breathing.
Motor neurons differ from sensory neurons, which receive input from
the environment and pass that information to the brain. For example, the
soft feel of a kitten’s fur would be communicated to the brain through
the function of the sensory neurons. The brain might then signal back
to the motor neurons to pet the cat in reaction to the feeling of soft fur.
Motor neurons regulate your ability to raise or lower your arm, control
the movement of your hand, apply the correct amount of pressure to the
kitten, position the location of your fingers relative to each other, and
produce a smile. In addition to controlling the movement of the arms,
hands and fingers, motor neurons play an important role in coordinating
these motions resulting in a smooth flow of body movements.
Our ability to produce a response to our environment relies on
the motor neuron system. To slowly lose these abilities over time cre-
ates ­dramatic problems in carrying out normal functions that we take
for granted in our daily lives. ALS is unique among MND because
 INTRODUCTION
xi

symptoms show dysfunction of both upper motor neurons and lower

motor ­neurons. Upper motor neurons are located primarily in the
brain and transmit information from the brain to the brain stem and
­spinal cord where the lower motor neurons are located. The lower motor
­neurons extend from the brain stem and spinal cord to specific muscle
cells. Involvement of both classes of motor neurons in ALS suggests a
different mechanism of disease onset or progression from other muscular
diseases. To appreciate this distinction, it is important to understand how
the brain, spinal cord, and certain muscle cells generally coordinate their
functions to produce muscle movement.

Muscles Need Motor Neurons

The brain consists of a huge number of neurons (estimated at 100 b­ illion)
which can be classified based on their relative location within the brain
and their functions. For example, the cerebral cortex of the brain includes
the neocortex which is a thin layer on the outside edge of the brain.
The neocortex, also called gray matter, folds in and out and creates the
well-known wrinkled texture and overall contours of the brain. The
­neocortex contains well-characterized sublayers of specialized cells and
supporting structures that change in different regions of the brain.
Vision is controlled by the visual cortex located in the occipital lobe (back
of the head) which has a distinct layering structure of cells compared to
the motor cortex, which controls muscle movement. The motor cortex is
located in the frontal lobe of the brain and involves many subregions to
allow the complex communication and smooth movement that we use in
our daily lives.
The shape and function of motor neurons allow them to provide a
communication bridge between important parts of our central nervous
system. Structurally, a neuron can be described as having a main nerve
cell body, dendrites which extend from the cell body and receive infor-
mation, and the axons which also extend from the cell body and pass
information to the next neuron. Axons and dendrites can be surprisingly
long. For upper motor neurons, the axons of a single neuron can e­ xtend
from the brain to the brain stem. Lower motor neurons can extend axons
from the brain stem or spinal cord directly to muscles. Some of the longest
xii INTRODUCTION

neurons of the body are lower motor neurons which can be up to 3.3 feet
long to reach distal muscles of the body. These long and potentially fragile
structures are protected by additional cells that form myelin sheaths along
the axons. Myelin insulation also ensures that the electrical signal moving
down the axon does not dissipate or weaken. Dissipation of signal would
result in a loss of motor neuron function.
Together, upper and lower motor neurons stimulate muscle contrac-
tion. Dendrites from the correct lower motor neuron receives signal from
an upper motor neuron. The stimulated lower motor neuron passes that
information through the cell body to axons which terminate at a contact
site on the target muscle. If the signal to contract degrades, or is lost at
any point along the upper or lower neuron transmission, muscles will
not contract. Since lower motor neurons stimulate muscle contraction,
loss of lower motor neuron function is associated with muscle weakness.
Upper motor neurons control the lower motor neurons. Failure to initiate
the signal for muscle contraction by the upper motor neurons would also
cause muscle weakness because the lower motor neurons are not ­activated.
It is important to note that in addition to initiating the ­signal to c­ ontract
muscles, upper motor neurons are also responsible for ­ stopping or
inhibiting lower motor neurons when it is time to stop contracting the
muscles. For this reason, dysfunction of the upper motor neurons can also
produce symptoms of continuous muscle contraction. In other words, if
the upper motor neuron cannot turn off the lower motor neuron, then
the muscle will be continuously stimulated to contract resulting in spasms
of the muscle. Since defects in both upper and lower motor neurons are
associated with ALS, symptoms of both muscle weakness and muscle
spasm are present. These two features are carefully considered during
­diagnosis of ALS.
In the following chapters, the current understanding of ALS will
be summarized focusing on symptoms, diagnosis, and causes that are
related to current and future treatments of the disease. Chapter 1 ­describes
symptoms and diagnosis of ALS. Symptoms can be subtle at first, and
­diagnosis of the disease requires an understanding of those ­clinical fea-
tures that distinguish it from other forms of motor neuron diseases or
causes of muscle impairment. While no clear cause or initial trigger of ALS
has been convincingly described, Chapter 2 focuses on potential causes
 INTRODUCTION
xiii

of ALS including motor neuron and neurotransmitter function as they

relate to the disease. Risk factors associated with the disease ranging from
genetic components to environmental factors are also described. C ­ hapter 3
addresses treatments and therapies. No cure exists for ALS, but ­treatments
that target neurotransmitter levels provide temporary ­relief from some
symptoms of the disease. The important role of the caretaker and a team
of specialized therapists in maintaining the health of an ALS patient
are addressed. Chapter 4 looks to the future work related to ALS and the
potential for treatments that provide improvement in muscle function or
ideally prevent disease initiation or progression.
 CHAPTER 1

Symptoms and Diagnosis

The initial symptoms of muscle weakness and spasm associated with

amyotrophic­lateral sclerosis (ALS) may be overlooked because they can
vary from patient to patient and initially be subtle. As time progresses,
subtle symptoms will develop into more obvious symptoms. Symptoms
can occur in any muscle group, though initial symptoms are frequently­
associated with limb or bulbar muscles. ALS symptoms can include
­
spasticity­ ­ (stiffness), increased reflexes, weakness of muscles, muscle
­atrophy or ­wasting, or fasciculation (twitching). Loss of upper motor
­neuron function­is associated with symptoms of muscle stiffness, spasm, slow
movement, and overactive reflex responses and eventually the loss of c­ ontrol
of voluntary muscles. Lower motor neuron loss causes symptoms­more
­associated with loss of muscle function, muscle weakness, muscle wasting­
and twitching. Typically, when symptoms progress more slowly early in the
disease, they will continue to progress more slowly at later disease stages.
Likewise, when symptoms progress more quickly early in disease
progression,­they will ­continue to progress more quickly in later stages. ALS
rarely ­interferes with the patient’s personality or ability­to think, though
some studies ­suggest that cognitive loss may occur at later stages of disease
progression. ­Approximately 50 percent of ALS p ­ atients develop pseudo-
bulbar emotional lability independent of other symptoms.­In this case,
the patient will cry, laugh, or yawn without control leading the patient
to a sense of a loss of mental control. These symptoms do not correlate
with cognitive decline and do not necessarily indicate a mood disorder,
but can be socially difficult and very disturbing for the patient. Depression
as a ­consequence of decreased body function is frequent in ALS patient
and caregivers. There is no cure for ALS, and once diagnosed, expecta-
tions are that the patient will die from respiratory failure, as occurs in 80 to
2 NERVE DISEASE ALS AND GRADUAL LOSS OF MUSCLE FUNCTION

90 percent of the cases. Other causes of death from ALS include heart fail-
ure (10 percent); pneumonia and suicide at a much lower frequencies.
The early signs of ALS vary among patients because different
motor neurons lose function and loss of those motor neurons would
affect muscle­function in different parts of the body. Historically,
ALS has been d ­ escribed based on the region of the body where symp-
toms are first noticed.­When symptoms start in a limb, it is described
as limb-onset ALS, if it begins with speech (dysarthia) or swallowing
­(dysphagia) problems, it is called bulbar-onset ALS. Bulbar-onset ALS
is named for the location of the motor neurons that are involved,
­specifically the corticobulbar region of the brain stem. Both limb-onset
and bulbar-onset ALS involve the loss of upper and lower motor ­neuron
functions. Limb-onset ALS can begin in the lower limbs or upper limbs
and can involve one limb with ­progression to the other or initiate
simultaneously in both limbs. While the average life expectancy after
diagnosis for ALS patients ranges ­between 2 and 5 years, approximately
5 percent of patients survive for more than 10 years and that population
usually has limb-onset ALS. Slower rates of disease progression are also
associated with rare forms of limb-onset ALS where progressive ­wasting
and weakness of one or more limbs occur with d ­ elayed progression to
other parts of the body. Bulbar-onset ALS p ­ rogresses more quickly than
limb-onset ALS and occurs in approximately 25 to 30 p ­ ercent of all
ALS cases.
Limb-onset ALS symptoms initially present as the patient having
­difficulty carrying out manual tasks that require coordination between the
legs and/or arms. For example, the patient might experience tripping­or
gait changes due to motor neuron dysfunction in the legs. Motor neuron­
dysfunction in the arms might result in a reduction in fine motor skills so
that buttoning clothes or writing become noticeably difficult. Symptoms
can also include difficulty in raising arms or moving the e­ ntire body to
climb stairs or to get out of chairs. Over time, fasciculation­(twitches)
might develop in addition to slowness in movement and ­reduced dexterity.­
Patients with symptoms of limb-onset ALS will eventually­develop b­ ulbar
ALS symptoms in later stages of the disease. Speech may be affected
along with spasms of the jaw, face, voice box, throat, and tongue. Specific­
symptoms associated with bulbar-onset ALS that affect speech include
 Symptoms and Diagnosis 3

poor articulation, strained voice, breathy speech pattern, and a decrease

in the range of pitch or loudness of the voice. At times, vocal cord spasms
can create the feeling that air is not being moved in and out of the lungs.
Eye muscles are not usually involved, and so dysfunction of the eyes is
not strongly associated with ALS. Approximately 93 percent of patients
with bulbar-onset ALS lose speech, 86 percent have difficulty swallowing,
64 percent show tongue twitching, and 19 percent experience vocal cord
spasms. In both limb- and bulbar-onset ALS, as the disease progresses,
patients will lose voluntary muscle control, which will impact the ability
of the patient to move, and so they may need mechanical assistance in
doing so. Patients may become unable to communicate verbally. Eventu-
ally, patients experience difficulty breathing and may need noninvasive or
invasive breathing assistance. Most ALS patients succumb to the disease
because of respiratory failure.

Diagnosing ALS
Given that ALS symptoms can vary among patients and exhibit subtle
onset, initial diagnosis focuses on ruling out other possible causes for
the symptoms presenting in the patient. Even in the case of symptoms
­involving both upper and lower motor neurons, other diseases are ruled out
before the diagnosis of ALS. In order to establish that the upper and lower
motor neurons are functioning properly, specific tests are given to measure
neuron function. In the case of lower motor neurons, one ­common test is
the electromyography or EMG. During EMG, a device­measures neuro-
nal movement of electrical signal during a voluntary­muscle­contraction­
to detect changes in the electrical signals in the muscle.­Nerve conduction
studies (NCS) are frequently performed in conjunction with the EMG to
assess speed and intensity of nerve impulses. In this case, the stimulation
to the nerve is applied to the surface of the skin through small electrodes
to stimulate the muscle, and successful muscle stimulation is measured by
additional electrodes. Certain EMG and NCS test result patterns are con-
sistent with ALS, but other patterns might support the diagnosis of dif-
ferent diseases such as peripheral neuropathy. Blood and urine tests would
likely be used to rule out other possible causes of the patient’s symptoms.
For example, the presence of high levels of creatine kinase in the blood
4 NERVE DISEASE ALS AND GRADUAL LOSS OF MUSCLE FUNCTION

system is more consistent with muscular dystrophies than with ALS. There
are also many infectious diseases that can give rise to symptoms associ-
ated with ALS. HIV infection, polio, Lyme disease, and West Nile virus
are examples of infectious agents that might need to be ruled out before
diagnosing a patient with ALS.
ALS is characterized by defects in both upper and lower motor
neurons, so tests to measure upper motor neuron function are also
used. Magnetic resonance imaging (MRI) scans can provide insight
into brain structures. The MRI captures a detailed series of images that
show cross-sections through the brain. Briefly, MRI uses a very strong
magnet to align the polarity (a type of directionality) of the ­hydrogens
(protons) present in our body (largely found in water). A radio wave is
passed through the patient to make the protons change direction. Once
the radio wave is removed, the protons move back to their o­ riginal
orientations releasing energy. This released energy is sensed by the
­machine to generate an image based on how quickly the energy is
­released from the protons. The result is a series of very high-resolution
images showing the relative size and position of tissues and organs in the
human body. In the case of ALS, these imaging techniques permit the
detection of other potential causes of upper motor neuron dysfunction
such as tumors of the brain or spinal cord, inflammation, ­infection,
stroke, and head injuries from trauma. A variation of the MRI called
­diffusion tensor MRI and magnetic resonance spectroscopic
­imaging (MRSI) aid in ALS diagnosis. These tests allow detection
of N­ -acetylaspartate (NAA) in whole brain scans. NAA is present
at very high levels in the brain and its chemical structure makes it a
very good candidate for detection by MRSI. While the function of
NAA in the brain is unclear, it is reduced in certain areas of the brain
in ALS ­patients. Another approach to detect dysfunction in upper
motor ­neuron activity is transcranial magnetic stimulation, where a
­magnetic pulse is applied to the brain, and electrodes are used to detect
electrical activity in various muscles. This approach is also useful in
monitoring disease progression.
Together, results from these tests and presenting symptoms allow
a physician to determine the functionality of upper and lower motor
neurons. ALS is characterized by changes in functions of both of these
 Symptoms and Diagnosis 5

classes of neurons in contrast to an individual who shows defects in

only upper motor neuron function or in only lower motor neuron
function. Problems with only upper motor neuron function might
indicate primary lateral sclerosis, whereas only lower motor neuron
dysfunction might be caused by progressive muscular atrophy. Once
the physician has gathered information relevant to the ALS diagnosis,
this information is combined with an ALS functional-rating scale for
final diagnosis. Given the potential for rapid disease progression, once
a diagnosis of ALS is determined, appropriate treatments and therapies
should be accessed quickly by the patient.
 Index
Aggressive nutritional therapies, 19 Chemical synapse, 8–9
Alleles, of gene, 11 Chromosome 21, 13
ALS Biomarker, 22–23 CK2017357, 21
Amyotrophic lateral sclerosis (ALS), ix Clinical Research in ALS and related
causes and contributing disorders for Therapeutic
factors of, 7–15 development (CReATe), 23
defined, x–xi Clinical trials, 21, 22
diagnosing, 3–5, 19 Cognitive loss, 1
familial, 11 Computer-assisted communication, 18
future prospects, 21–23 Corticobulbar region, 2
genetic contributions to, 11–14 Creatine kinase, 3–4
national health registry for, 14–15
neurotransmitters and, 7–11 Deftriaxone, 21
potential causes of, 14–15 Dendrites, xi
prevention of, 22–23 Depression, 1
sporadic, 11 Dexpramipexole, 21
symptoms and diagnosis of, 1–5 Diffusion tensor MRI, 4
treatment and therapy for, 17–20 Disease progression, 19–20
Anticonvulsants, 18 DNA, 11, 12, 14
Antidepressants, 18 Dysarthia, 2
Apoptosis, 10 Dysphagia, 2, 17–18
Atrophy, 21
Axons, xi, 8, 22 Electrical signals, 3, 8, xii
Electrical stimulus, 8
Bilevel positive airway pressure Electrodes, 4
therapy, 18 Electromyography (EMG), 3
Blood test, 3 End of life decisions, 20
Braces, 18 Environmental toxins, 11
Brain stem, xi Epigenetic changes, 14
Breathing therapists, 18 Estimation, ix
Bulbar muscles, 1 Excitatory amino acid transporter 2
Bulbar-onset ALS, 2 (EAAT2) protein, 14
Exitotoxicity, 10
C9orf72, 12
Caregivers, ix Familial ALS, 11, 14
support for, 19–20 Fasciculation, 1, 2
training for, 20 FDA, 21
Cells, x Feeding tubes, 18
Cellular irregularities, with ALS, 14 Frontotemporal dementia (FTD), 12
Cerebral cortex, xi Fused in sarcoma/translated in
Cerebrospinal fluid, 9 liposarcoma (FUS/TLS), 13
38 INDEX
Gene mutations, 13
Genome wide molecular approach, 23
Glial cells, x, 8, 10, 22
Glutamate, 9–10, 14
Gray matter. See Neocortex
HIV infection, 4
Human stem cells, 21–22
types of, 22
Imaging techniques, 4, 23
Imaging technology, 10
Induced pluripotent stem cells, 22
Infectious diseases, 4
Life expectancy, for ALS patient, 2
Limb-onset ALS, 2
Lou Gehrig’s disease. See Amyotrophic
lateral sclerosis (ALS)
Lower motor neurons, xi–xii
cell bodies of, 8
loss of, 1
Lyme disease, 4
Magnetic resonance imaging (MRI), 4
Magnetic resonance spectroscopic
imaging (MRSI), 4
Mechanical ventilation, 19
Motor cortex, xi
Motor end plates, 8
Motor neuron atrophy, 10
Motor neuron disease (MND), x
Motor neuron dysfunction,
2, 7, 21, 22
Motor neurons, x–xi, 7, 8, 22
death of, 7
muscles, need for, xi–xiii
shape and function of, xi
Multidisciplinary team-oriented
approach, 19
Muscles, xi–xiii
contraction of, 8, 10
function of, x
relaxants of, 17
stimulation, 3
Muscle atrophy, 1
Muscle weakness, 1, 21
Myelin insulation, xii
N-acetylaspartate (NAA), 4, 22
National estimates, ix
National health registry, ix
National Institutes of Health
(NIH), 23
Nationally notifiable condition, ix
Neocortex, xi
Nerve cell body, xi
Nerve conduction studies (NCS), 3
Nervous system, x
Neurodegenerative diseases, 22
Neuromuscular junction (NMJ), 8
schematic representation of, 9
Neuron atrophy, 13
Neurons, x, 21–22
Neuron toxicity, 10
Neurotransmitters, 7–11, 8
diffusion of, 9
Noninvasive ventilation systems, 19
NP001 drug, 21
Nutritional concerns, 18
Occupational therapy, 18
Pain, 18
Physical therapy, 18
Physiological measures, of neuron, 23
Polio, 4
Primary lateral sclerosis, 5
Professional therapists, role of, 19
Progressive muscular atrophy, 5
Pseudobulbar effect, 17
Pseudobulbar emotional lability, 1
Quality of life, 19, 20
Radio wave, 4
Rapid progression, 17
Rare Diseases Clinical Research
Consortium (RDCRC), 23
Rare Diseases Clinical Research
Network (RDCRN), 23
Respiratory failure, 18
Riluzole drug, 17
RNA, 12
Salivary glands, 18
Secretory vesicles, 8
 INDEX
39

Sensory neurons, x Tracheostomy, 19

Social worker, 18 Transcranial magnetic stimulation, 4
Spasticity, 1, 17
Speech aids, 18 Ubiquilin 2 (UBQLN2), 13
Speech therapy, 18 Unifying theory, 10
Spinal cord, xi Upper motor neurons, xi–xii
Splicing, 12 loss of, 1
Sporadic ALS, 11, 14 Urine test, 3
Stem cell therapy, 21–22 U. S. Food and Drug
Superoxide dismutase Administration (FDA), 17
gene (SOD1), 13
Synaptic cleft, 8 Ventilator system, 19
Synaptic end bulbs, 8, 22 Vision, xi
Vocal cord spasms, 3
TARDBP gene, 12
TAR DNA binding protein 43 West Nile virus, 4
(TDP-43), 12 Wheelchairs, 18
Therapeuticstem cells, 22 Whole-genome sequence analysis, 11
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