Electrical stimulation combined with exercise increase axonal regeneration after peripheral nerve injury

Chinese tuina downregulates the elevated levels of tissue plasminogen activator in sciatic nerve injured Sprague-Dawley rats

OBJECTIVE

To elucidate the mechanism of Chinese tuina in treating sciatic nerve crush injury, and to detect the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1), which is thought to play an important role in nerve regeneration.

METHODS

Thirty-two adult male Sprague-Dawley rats were subjected to sciatic nerve crush injury and 16 rats (sham-operated group) went through a sham operation. Control group was given no treatment while tuina group received tuina therapy since day 7 post-surgery. Tuina treatment was performed once a day and lasted for 20 days. The sciatic functional index was examined every 5 days during the treatment session. The rats' gastrocnemius muscles were evaluated for changes in mass and immunohistochemistry techniques were performed to detect the levels of tPA and PAI-1.

RESULTS

Tuina therapy improved the motor function of sciatic nerve injured rats (P<0.05), however, it did not increase muscle volume (P<0.05). Tuina downregulated the levels of tPA and PAI-1 (P<0.05).

CONCLUSIONS

The present study implies that tuina treatment could accelerate rehabilitation of peripheral nerve injury.

Effects of physical exercise on the functional recovery of rat hindlimbs with impairments of the sciatic nerve as assessed by 2D video analysis

[Purpose] The purpose of this study was to investigate the effects of treadmill training on functional recovery by analyzing the ankle joint as well as the knee and hip joints with 2D video analysis during gait by rats with sciatic nerve injury. [Subjects and Methods] Twenty-four male Sprague-Dawley rats were used in this study. The sham group (SG) received only a sham operation without any sciatic injury; the training group (TG) performed treadmill training for 4 weeks after sciatic injury; and the control group (CG) wasn’t provided with any therapeutic intervention after sciatic injury. [Results] The ankle, knee, and hip ROM of TG and CG during the initial, mid stance, and toe-off phases of gait at post-test were significantly different from SG. [Conclusion] Physical exercise, like treadmill training, is beneficial for the improvement of the ankle, knee and hip joints of rats with crushed sciatic nerve injury.

The effect of weight-bearing exercise and non-weight-bearing exercise on gait in rats with sciatic nerve crush injury

[Purpose] The purpose of this study was to access the effect of weight bearing exercise (treadmill exercise) and non-weight-bearing exercise (swimming exercise) on gait in the recovery process after a sciatic nerve crush injury. [Subjects and Methods] Rats were randomly divided into a swimming group (n=3) with non-weight-bearing exercise after a sciatic nerve crush and a treadmill group (n=3) with weight bearing exercise after a sciatic nerve crush. Dartfish is a program that can analyze and interpret motion through video images. The knee lateral epicondyle, lateral malleolus, and metatarsophalangeal joint of the fifth toe were marked by black dots before recording. [Results] There were significant differences in TOK (knee angle toe off) and ICK (knee angle at initial contact) in the swimming group and in TOK, ICA (ankle angle at initial contact), and ICK in the treadmill group. In comparison between groups, there were significant differences in TOA (ankle angle in toe off) and ICA at the 7th day. [Conclusion] There was no difference between weight bearing and non-weight-bearing exercise in sciatic nerve damage, and both exercises accelerated the recovery process in this study.

Brief electrical stimulation improves nerve regeneration after delayed repair in Sprague Dawley rats

Functional recovery after peripheral nerve injury and surgical repair declines with time and distance because the injured neurons without target contacts (chronic axotomy) progressively lose their regenerative capacity and chronically denervated Schwann cells (SCs) atrophy and fail to support axon regeneration. Findings that brief low frequency electrical stimulation (ES) accelerates axon outgrowth and muscle reinnervation after immediate nerve surgery in rats and human patients suggest that ES might improve regeneration after delayed nerve repair. To test this hypothesis, common peroneal (CP) neurons were chronically axotomized and/or tibial (TIB) SCs and ankle extensor muscles were chronically denervated by transection and ligation in rats. The CP and TIB nerves were cross-sutured after three months and subjected to either sham or one hour 20Hz ES. Using retrograde tracing, we found that ES significantly increased the numbers of both motor and sensory neurons that regenerated their axons after a three month period of chronic CP axotomy and/or chronic TIB SC denervation. Muscle and motor unit forces recorded to determine the numbers of neurons that reinnervated gastrocnemius muscle demonstrated that ES significantly increased the numbers of motoneurons that reinnervated chronically denervated muscles. We conclude that electrical stimulation of chronically axotomized motor and sensory neurons is effective in accelerating axon outgrowth into chronically denervated nerve stumps and improving target reinnervation after delayed nerve repair. Possible mechanisms for the efficacy of ES in promoting axon regeneration and target reinnervation after delayed nerve repair include the upregulation of neurotrophic factors.

Far-Infrared Therapy Promotes Nerve Repair following End-to-End Neurorrhaphy in Rat Models of Sciatic Nerve Injury

This study employed a rat model of sciatic nerve injury to investigate the effects of postoperative low-power far-infrared (FIR) radiation therapy on nerve repair following end-to-end neurorrhaphy. The rat models were divided into the following 3 groups: (1) nerve injury without FIR biostimulation (NI/sham group); (2) nerve injury with FIR biostimulation (NI/FIR group); and (3) noninjured controls (normal group). Walking-track analysis results showed that the NI/FIR group exhibited significantly higher sciatic functional indices at 8 weeks after surgery (P < 0.05) compared with the NI/sham group. The decreased expression of CD4 and CD8 in the NI/FIR group indicated that FIR irradiation modulated the inflammatory process during recovery. Compared with the NI/sham group, the NI/FIR group exhibited a significant reduction in muscle atrophy (P < 0.05). Furthermore, histomorphometric assessment indicated that the nerves regenerated more rapidly in the NI/FIR group than in the NI/sham group; furthermore, the NI/FIR group regenerated neural tissue over a larger area, as well as nerve fibers of greater diameter and with thicker myelin sheaths. Functional recovery, inflammatory response, muscular reinnervation, and histomorphometric assessment all indicated that FIR radiation therapy can accelerate nerve repair following end-to-end neurorrhaphy of the sciatic nerve.

Delaying the onset of treadmill exercise following peripheral nerve injury has different effects on axon regeneration and motoneuron synaptic plasticity

Transection of a peripheral nerve results in withdrawal of synapses from motoneurons. Some of the withdrawn synapses are restored spontaneously, but those containing the vesicular glutamate transporter 1 (VGLUT1), and arising mainly from primary afferent neurons, are withdrawn permanently. If animals are exercised immediately after nerve injury, regeneration of the damaged axons is enhanced and no withdrawal of synapses from injured motoneurons can be detected. We investigated whether delaying the onset of exercise until after synapse withdrawal had occurred would yield similar results. In Lewis rats, the right sciatic nerve was cut and repaired. Reinnervation of the soleus muscle was monitored until a direct muscle (M) response was observed to stimulation of the tibial nerve. At that time, rats began 2 wk of daily treadmill exercise using an interval training protocol. Both M responses and electrically-evoked H reflexes were monitored weekly for an additional seven wk. Contacts made by structures containing VGLUT1 or glutamic acid decarboxylase (GAD67) with motoneurons were studied from confocal images of retrogradely labeled cells. Timing of full muscle reinnervation was similar in both delayed and immediately exercised rats. H reflex amplitude in delayed exercised rats was only half that found in immediately exercised animals. Unlike immediately exercised animals, motoneuron contacts containing VGLUT1 in delayed exercised rats were reduced significantly, relative to intact rats. The therapeutic window for application of exercise as a treatment to promote restoration of synaptic inputs onto motoneurons following peripheral nerve injury is different from that for promoting axon regeneration in the periphery.

Tubulization with chitosan guides for the repair of long gap peripheral nerve injury in the rat

Biosynthetic guides can be an alternative to nerve grafts for reconstructing severely injured peripheral nerves. The aim of this study was to evaluate the regenerative capability of chitosan tubes to bridge critical nerve gaps (15 mm long) in the rat sciatic nerve compared with silicone (SIL) tubes and nerve autografts (AGs). A total of 28 Wistar Hannover rats were randomly distributed into four groups (n = 7 each), in which the nerve was repaired by SIL tube, chitosan guides of low (∼2%, DAI) and medium (∼5%, DAII) degree of acetylation, and AG. Electrophysiological and algesimetry tests were performed serially along 4 months follow-up, and histomorphometric analysis was performed at the end of the study. Both groups with chitosan tubes showed similar degree of functional recovery, and similar number of myelinated nerve fibers at mid tube after 4 months of implantation. The results with chitosan tubes were significantly better compared to SIL tubes (P < 0.01), but lower than with AG (P < 0.01). In contrast to AG, in which all the rats had effective regeneration and target reinnervation, chitosan tubes from DAI and DAII achieved 43 and 57% success, respectively, whereas regeneration failed in all the animals repaired with SIL tubes. This study suggests that chitosan guides are promising conduits to construct artificial nerve grafts.

The neuroprotective benefit from pioglitazone (PIO) addition on the alpha lipoic acid (ALA)-based treatment in experimental diabetic rats

In this study, we investigated the combined effect of pioglitazone (PIO) with alpha lipoic acid (ALA) on the peripheral nerves of diabetic rats. Animals were divided into 8 groups (N = 6-8) and designated according to ALA (100 mg/kg/day) and PIO (10 mg/kg/day) treatment: Normal, Normal + ALA, Normal + PIO, Normal + ALA + PIO, DM, DM + ALA, DM + PIO, and DM + ALA + PIO. After 24 weeks, current perception threshold, mechanical allodynia, oxidative stresses, intraepidermal nerve fiber density (IENFD), and axonal morphology in the sciatic nerve were compared among groups. IENFD in the DM + ALA + PIO group was significantly less reduced than in other DM groups (7.61 ± 0.52 vs. 5.62 ± 0.96, 5.56 ± 0.60, and 7.10 ± 0.70 for DM, DM + ALA, and DM + PIO, respectively P < 0.05). The mean myelinated axonal area in the sciatic nerves was significantly higher in the DM + ALA + PIO group compared with non-treated DM group (70.2 ± 3.46 vs. 61.1 ± 2.91, P < 0.05) although significant differences were not present between combination therapy and monotherapy independent of ALA or PIO. Our results demonstrated that combination therapy using PIO based on ALA can give an additional benefit in peripheral nerve preservation in diabetes. Moreover, PIO can be preferentially considered when additional glucose-lowering agent is required in DPN patients treated with ALA.

Balance and coordination training and endurance training after nerve injury

INTRODUCTION

Different rehabilitation treatments have proven useful in accelerating regeneration.

METHODS

After sciatic nerve crush in rats, we tested balance and coordination training (BCT) and endurance training (ET) through sensorimotor tests and analyzed nerve and muscle morphology.

RESULTS

After BCT and ET, rats performed better in sensorimotor tests than did non-trained animals. However, only BCT maintained sensorimotor function during training. Furthermore, BCT and ET produced significantly larger muscle area than in non-trained animals.

CONCLUSIONS

These findings indicate that BCT and ET, when initiated in the early phase after sciatic nerve injury, improve morphological properties of the soleus muscle and sciatic nerve, but only the task-oriented BCT maintained sensorimotor function. The success of rehabilitative strategies appears to be highly task-specific, and strategies that stimulate sensory pathways are the most effective in improving balance and/or coordination parameters.

Activity dependent therapies modulate the spinal changes that motoneurons suffer after a peripheral nerve injury

Injury of a peripheral nerve not only leads to target denervation, but also induces massive stripping of spinal synapses on axotomized motoneurons, with disruption of spinal circuits. Even when regeneration is successful, unspecific reinnervation and the limited reconnection of the spinal circuits impair functional recovery. The aim of this study was to describe the changes that axotomized motoneurons suffer after peripheral nerve injury and how activity-dependent therapies and neurotrophic factors can modulate these events. We observed a marked decrease in glutamatergic synapses, with a maximum peak at two weeks post-axotomy, which was only partially reversed with time. This decrease was accompanied by an increase in gephyrin immunoreactivity and a disintegration of perineuronal nets (PNNs) surrounding the motoneurons. Direct application of neurotrophins at the proximal stump was not able to reverse these effects. In contrast, activity-dependent treatment, in the form of treadmill running, reduced the observed destructuring of perineuronal nets and the loss of glutamatergic synapses two weeks after injury. These changes were proportional to the intensity of the exercise protocol. Blockade of sensory inputs from the homolateral hindlimb also reduced PNN immunoreactivity around intact motoneurons, and in that case treadmill running did not reverse that loss, suggesting that the effects of exercise on motoneuron PNN depend on increased sensory activity. Preservation of motoneuron PNN and reduction of synaptic stripping by exercise could facilitate the maintenance of the spinal circuitry and benefit functional recovery after peripheral nerve injury.

The protective effects of DA-9801 (Dioscorea extract) on the peripheral nerves in streptozotocin-induced diabetic rats

It has been reported that DA-9801, an extract mixture of Dioscorea japonica Thunb and Dioscorea nipponica Makino, produces a neurotrophic activity. Therefore, this study was conducted to examine the neuroprotective effects of DA-9801 in streptozotocin-induced diabetic rats. The experimental rats were divided into six groups: the control group, Group I (non-diabetic rats treated with DA-9801), Group II (diabetic, non-treated rats) and Groups III, IV, and V (diabetic rats treated with DA-9801 at doses of 10, 50 or 100 mg/kg/d). Following a 16-wk course of oral treatment with DA-9801, functional parameters (von Frey filament test, hot plate test), biochemical parameters (nerve growth factor (NGF), tumor necrosis factor (TNF)-α, interleukin (IL)-6) were measured. An immunohistochemical staining was done to assess the neuroprotective effects of DA-9081 in the skin, sciatic nerve, gastric mucosa and renal cortex. In Week 8, pain was evoked by either tactile or thermal stimuli, whose threshold was significantly higher in Group III, IV and V than Group II. Western blot analysis showed a more significant increase in NGF and decrease in TNF-α and IL-6 in Group III, IV and V than in Group II (p<0.05). Moreover, following the treatment with DA-9801, a loss of intraepidermal nerve fibers (IENFs) was inhibited to a significant level in the skin, myelinated axonal fibers of the sciatic nerve and small nerve fibers innervating the gastric mucosa or renal cortex (p<0.05). Our results demonstrated that DA-9801 is a beneficial agent that protects the peripheral nerves in diabetic rats.

The parameters of transcutaneous electrical nerve stimulation are critical to its regenerative effects when applied just after a sciatic crush lesion in mice

We investigated the effect of two frequencies of transcutaneous electrical nerve stimulation (TENS) applied immediately after lesion on peripheral nerve regeneration after a mouse sciatic crush injury. The animals were anesthetized and subjected to crushing of the right sciatic nerve and then separated into three groups: nontreated, Low-TENS (4 Hz), and High-TENS (100 Hz). The animals of Low- and High-TENS groups were stimulated for 2 h immediately after the surgical procedure, while the nontreated group was only positioned for the same period. After five weeks the animals were euthanized, and the nerves dissected bilaterally for histological and histomorphometric analysis. Histological assessment by light and electron microscopy showed that High-TENS and nontreated nerves had a similar profile, with extensive signs of degeneration. Conversely, Low-TENS led to increased regeneration, displaying histological aspects similar to control nerves. High-TENS also led to decreased density of fibers in the range of 6-12 μm diameter and decreased fiber diameter and myelin area in the range of 0-2 μm diameter. These findings suggest that High-TENS applied just after a peripheral nerve crush may be deleterious for regeneration, whereas Low-TENS may increase nerve regeneration capacity.

Treadmill exercise induced functional recovery after peripheral nerve repair is associated with increased levels of neurotrophic factors

Benefits of exercise on nerve regeneration and functional recovery have been reported in both central and peripheral nervous system disease models. However, underlying molecular mechanisms of enhanced regeneration and improved functional outcomes are less understood. We used a peripheral nerve regeneration model that has a good correlation between functional outcomes and number of motor axons that regenerate to evaluate the impact of treadmill exercise. In this model, the median nerve was transected and repaired while the ulnar nerve was transected and prevented from regeneration. Daily treadmill exercise resulted in faster recovery of the forelimb grip function as evaluated by grip power and inverted holding test. Daily exercise also resulted in better regeneration as evaluated by recovery of compound motor action potentials, higher number of axons in the median nerve and larger myofiber size in target muscles. Furthermore, these observations correlated with higher levels of neurotrophic factors, glial derived neurotrophic factor (GDNF), brain derived neurotrophic factor (BDNF) and insulin-like growth factor-1 (IGF-1), in serum, nerve and muscle suggesting that increase in muscle derived neurotrophic factors may be responsible for improved regeneration.

Chemotherapy-induced peripheral neuropathy: an algorithm to guide nursing management

Oncology nurses play a critical role in the assessment and management of chemotherapy-induced peripheral neuropathy (CIPN). Baseline and ongoing evaluation of physical function is a critical but often overlooked aspect of assessment of CIPN. The diversity of symptoms and the complexity associated with neuromuscular assessment lead to challenges in evaluation and management of CIPN. To meet this challenge, the authors devised a feasible algorithm to guide oncology nurses in the assessment and management of CIPN using techniques that can easily be implemented in a variety of clinical settings. Managing pain, maintaining safety, and maximizing physical function are the primary goals for nursing management of CIPN.

Enhancement of peripheral nerve regeneration due to treadmill training and electrical stimulation is dependent on androgen receptor signaling

Moderate exercise in the form of treadmill training and brief electrical nerve stimulation both enhance axon regeneration after peripheral nerve injury. Different regimens of exercise are required to enhance axon regeneration in male and female mice (Wood et al.: Dev Neurobiol 72 (2012) 688-698), and androgens are suspected to be involved. We treated mice with the androgen receptor blocker, flutamide, during either exercise or electrical stimulation, to evaluate the role of androgen receptor signaling in these activity-based methods of enhancing axon regeneration. The common fibular (CF) and tibial (TIB) nerves of thy-1-YFP-H mice, in which axons in peripheral nerves are marked by yellow fluorescent protein (YFP), were transected and repaired using CF and TIB nerve grafts harvested from non-fluorescent donor mice. Silastic capsules filled with flutamide were implanted subcutaneously to release the drug continuously. Exercised mice were treadmill trained 5 days/week for 2 weeks, starting on the third day post-transection. For electrical stimulation, the sciatic nerve was stimulated continuously for 1 h prior to nerve transection. After 2 weeks, lengths of YFP+ profiles of regenerating axons were measured from harvested nerves. Both exercise and electrical stimulation enhanced axon regeneration, but this enhancement was blocked completely by flutamide treatments. Signaling through androgen receptors is necessary for the enhancing effects of treadmill exercise or electrical stimulation on axon regeneration in cut peripheral nerves.

Effects of early and delayed laser application on nerve regeneration

The aim of this study is to analyze the differences between early and delayed use of low-level laser therapy (LLLT) in functional and morphological recovery of the peripheral nerve. Thirty male Wistar rats were divided into three groups after the sciatic nerve was crushed: (1) control group without laser treatment, (2) early group with laser treatment started immediately after surgery and lasted 14 days, and (3) delayed group with laser treatment starting on the postoperative day 7 and lasted until day 21. A 650-nm diode laser (model: DH650-24-3(5), Huanic, China) with an output power of 25 mW exposed transcutaneously at three equidistant points on the surgical mark corresponding to the crushed nerve. The length of the laser application was calculated as 57 s to satisfy approximately 10 J/cm(2). A Sciatic Functional Index (SFI) was used to evaluate functional improvement in groups at pre- and post-surgery (on days 7, 14, and 21). Compound action potential (CAP) was measured after the sacrifice and histological examination was performed for all groups. SFI results showed that there was no significant difference between groups at different days (p > 0.05). On the other hand, the latency of CAP decreased significantly (p < 0.05) in the delayed group. Histological examination confirmed that the number of mononuclear cells was lower (p < 0.05) in both early and delayed groups. In conclusion, results supported the hypothesis that LLLT could accelerate the rate of recovery of injured peripheral nerves in this animal model. Though both laser groups had positive outcomes, delayed group showed better recovery.

Sex differences in the effectiveness of treadmill training in enhancing axon regeneration in injured peripheral nerves

Exercise in the form of daily treadmill training results in significant enhancement of axon regeneration following peripheral nerve injury. Because androgens are also linked to enhanced axon regeneration, we wanted to investigate whether sex differences in the effect of treadmill training might exist. The common fibular nerves of thy-1-YFP-H mice were cut and repaired with a graft of the same nerve from a strain-matched wild-type donor mouse. Animals were treated with one of two daily treadmill training paradigms: slow continuous walking for 1 h or four higher intensity intervals of 2 min duration separated by 5-min rest periods. Training was begun on the third day following nerve injury and continued 5 days per week for 2 weeks. Effects on regeneration were evaluated by measuring regenerating axon profile lengths in optical sections through the repair sites and grafts at the end of the training period. No sex differences were found in untrained control mice. Continuous training resulted in significant enhancement of axon regeneration only in males. No effect was found in females or in castrated males. Interval training was effective in enhancing axon regeneration only in females and not in intact males or castrated males. Untrained females treated with the aromatase inhibitor, anastrozole, had significant enhancement of axon regeneration without increasing serum testosterone levels. Two different mechanisms exist to promote axon regeneration in a sex-dependent manner. In males treadmill training uses testicular androgens. In females, a different cellular mechanism for the effect of treadmill training must exist.

Effects of treadmill training on functional recovery following peripheral nerve injury in rats

Exercise, in the form of moderate daily treadmill training following nerve transection and repair leads to enhanced axon regeneration, but its effect on functional recovery is less well known. Female rats were exercised by walking continuously, at a slow speed (10 m/min), for 1 h/day on a level treadmill, beginning 3 days after unilateral transection and surgical repair of the sciatic nerve, and conducted 5 days/wk for 2 wk. In Trained rats, both direct muscle responses to tibial nerve stimulation and H reflexes in soleus reappeared earlier and increased in amplitude more rapidly over time than in Untrained rats. The efficacy of the restored H reflex was greater in Trained rats than in Untrained controls. The reinnervated tibialis anterior and soleus were coactivated during treadmill locomotion in Untrained rats. In Trained animals, the pattern of activation of soleus, but not tibialis anterior, was not significantly different from that found in Intact rats. The overall length of the hindlimb during level and up- and downslope locomotion was conserved after nerve injury in both groups. This conservation was achieved by changes in limb orientation. Limb length was conserved effectively in all rats during downslope walking but only in Trained rats during level and upslope walking. Moderate daily exercise applied immediately after sciatic nerve transection is sufficient to promote axon regeneration, to restore muscle reflexes, and to improve the ability of rats to cope with different biomechanical demands of slope walking.

Motor activity affects adult skeletal muscle re-innervation acting via tyrosine kinase receptors

Recently, muscle expression of brain-derived neurotrophic factor (BDNF) mRNA and protein under activity control has been reported. BDNF is a neurotrophin known to be involved in axon sprouting in the CNS. Hence, we set out to study the effect of chronic treadmill mid-intensity running on adult rat muscle re-innervation, and to explore the involvement of BDNF and tropomyosin-related kinase (Trk) receptors. After nerve crush, muscle re-innervation was evaluated using intracellular recordings, tension recordings, immunostaining and Western blot analyses. An enhanced muscle multiple innervation was found in running rats that was fully reversed to control values blocking Trk receptors or interrupting the running activity. An increase in muscle multiple innervation was also found in sedentary rats treated with a selective TrkB receptor agonist. The expression of TrkB receptors by intramuscular axons was demonstrated, and increased muscle expression of BDNF was found in running animals. The increase in muscle multiple innervation was consistent with the faster muscle re-innervation that we found in running animals. We conclude that, when regenerating axons contact muscle cells, muscle activity progressively increases modulating BDNF and possibly other growth factors, which in turn, acting via Trk receptors, induce axon sprouting to re-innervate skeletal muscle.

Therapeutic Potential of Dioscorea Extract (DA-9801) in Comparison with Alpha Lipoic Acid on the Peripheral Nerves in Experimental Diabetes

DA-9801, a mixture of extracts from Dioscorea japonica Thunb. and Dioscorea nipponica Makino, was reported to have neurotrophic activity. Therefore, we investigated the therapeutic potential of DA-9801, in comparison with alpha lipoic acid (ALA), for peripheral nerves preservation in experimental diabetes. Experimental animals were divided into 4 groups, and each group was designated according to the type of treatment administered as follows: normal, DM, DM+DA-9801, and DM+ALA. After 16 weeks, response thresholds to tactile and thermal stimuli were higher in DM+DA-9801 group than in nontreated DM group. This degree of increase in DM+DA-9801 group indicates more therapeutic potency of DA-9801 than ALA. Western blot analysis showed more significant increase in NGF and decrease in TNF-α and IL-6 in DM+DA-9801 group than in DM or DM+ALA groups (P < 0.05). IENF density was reduced less significantly in the DM+DA-9801 group than in other DM groups (7.61 ± 0.32, 4.2 ± 0.26, and 6.5 ± 0.30 in DM+DA-9801, DM, and DM+ALA, resp., P < 0.05). Mean myelinated axonal area in the sciatic nerves was significantly greater in DM+DA-9801 group than in other DM groups (69.2 ± 5.76, 54.0 ± 6.32, and 63.1 ± 5.41 in DM+DA-9801, DM, and DM+ALA, resp., P < 0.05). Results of this study demonstrated potential therapeutic applications of DA-9801 for the treatment of diabetic peripheral neuropathy.

Differential effects of activity dependent treatments on axonal regeneration and neuropathic pain after peripheral nerve injury

Activity treatments are useful strategies to increase axonal regeneration and functional recovery after nerve lesions. They are thought to benefit neuropathy by enhancing neurotrophic factor expression. Nevertheless the effects on sensory function are still unclear. Since neurotrophic factors also play a fundamental role in peripheral and central sensitization, we studied the effects of acute electrical stimulation and early treadmill exercise on nerve regeneration and on neuropathic pain, and the relation with the expression of neurotrophins. After sciatic nerve section and suture repair, rats were subjected to electrical stimulation (ES) for 4h after injury, forced treadmill running (TR) for 5 days, or both treatments combined. Sciatic nerve section induced hyperalgesia in the medial area of the plantar skin in the injured paw. TR and ES differently but positively reduced adjacent neuropathic pain before and after sciatic reinnervation. ES enhanced motor and sensory reinnervation, and combination with TR induced strong agonistic effects in relieving pain. The differential effects of these activity treatments were related to changes in neurotrophic factor mRNA levels in sensory and motor neurons. ES speeded up expression of BDNF and GDNF in DRG, and of BDNF and NT3 in the ventral horn. TR reduced the levels of pro-nociceptive factors such as BDNF, NGF and GDNF in DRG. Combination of ES and TR induced intermediate levels suggesting an optimal balancing of treatment effects.

Brief transvertebral electrical stimulation of the spinal cord improves the specificity of femoral nerve reinnervation

BACKGROUND

Functional outcomes are generally poor following peripheral nerve injury (PNI). The reason is multifactorial but includes the misdirection of regenerating axons to inappropriate end organs. It has been shown that brief electrical stimulation (Estim) of nerves has the potential to improve the accuracy and rate of peripheral axon regeneration.

OBJECTIVE

The present study explores a novel percutaneous transvertebral approach to Estim, which was tested in the mouse femoral nerve model.

METHODS

Inspired by the protocol of Gordon and colleagues (ie, 20 Hz, for 1 hour), we applied Estim to the cervicothoracic spinal cord (SC-Estim) to remotely activate lumbar motor neurons following transection and repair of the femoral nerve. Fluorescent dyes were applied to the distal nerve to label reinnervating cells. Sections of nerve were taken to quantify the numbers of reinnervating axons as well as to stain for a known femoral axon guidance molecule-polysialylated neural cell adhesion molecule (PSA-NCAM).

RESULTS

In comparison to sham treatment, SC-Estim led to significantly greater expression of PSA-NCAM as well as improved the specificity of motor reinnervation. Interestingly, although SC-Estim did not alter the number of early reinnervating (ie, pioneer) axons, there was a reduction in the number of retrogradely labeled neurons at 2 weeks postrepair. However, by 6 weeks postrepair, there was no difference in the number of neurons that had reinnervated the femoral nerve.

CONCLUSIONS

The present findings support the development of SC-Estim as a novel approach to enhance the specificity of reinnervation and potentially improve functional outcomes following PNI.

Interventions in the disturbances in the motor and sensory environment

Treatment of peripheral nervous system (PNS) pathology presents intervention challenges to every therapist. Many of the current and future interventions will be directed at restoring the normal anatomy, function, and biomechanical properties of the PNS, restoring normal neural physiology and ultimately patient function and quality of life. Present interventions use mechanical (movement) or electrical procedures to affect various properties of the peripheral nerve. The purpose of this article was to apply basic science to clinical practice. The pathology and accompanying structural and biomechanical changes in the PNS will be presented in three specific areas commonly encountered in the clinic: nerve injury and laceration; compression neuropathies; and neuropathic pain and neural tension dysfunction. The intent is to address possible interventions exploring the clinical reasoning process that combines basic science and evidence-based best practice. The current lack of literature to support any one intervention requires a strong foundation and understanding of the PNSs' structure and function to refine current and develop new intervention strategies. Current evidence will be presented and linked with future considerations for intervention and research. During this interlude of development and refinement, best practice will rely on sound clinical reasoning skills that incorporate basic science to achieve a successful outcome when treating these challenging patients.

Repercussões morfológicas e funcionais do exercício sobre a regeneração nervosa periférica

INTRODUÇÃO: A indicação de exercícios físicos como abordagem terapêutica após lesões nervosas periféricas, apesar de resultados clínicos favoráveis, ainda não é consenso na literatura pertinente. Objetivos: Este estudo buscou avaliar a interferência do exercício em roda motorizada no processo de regeneração nervosa periférica. MATERIAIS E MÉTODOS: Foram utilizados 48 ratos Wistar divididos proporcionalmente em quatro grupos de 12 ratos cada (seis controles e seis experimentais). Após treinamento, os ratos foram submetidos à axonotmese do nervo ciático direito. Todos os grupos iniciaram o regime de exercícios diários 24 horas após a lesão, porém com durações diferenciadas (G1 por 28 dias; G2 por 21 dias, G3 por 14 dias e G4 por sete dias). O exercício teve tempo e velocidade ajustados de acordo com o tempo de tratamento para cada grupo. RESULTADOS: Por meio do cálculo do Índice Funcional do Ciático, os animais submetidos ao exercício apresentaram sinais de atraso na recuperação funcional da marcha, em comparação a animais controles. Na análise histológica dos nervos lesionados, observou-se que animais exercitados apresentaram sinais de preservação dos axônios no coto proximal e de degeneração no coto distal, e os animais exercitados por somente sete dias não apresentaram a mesma característica degenerativa no coto distal. A aplicação de exercícios ativos e sem carga em animais que sofreram axonotmese interfere negativamente no processo de recuperação funcional de alguns parâmetros da marcha. CONCLUSÃO: Apesar de o exercício ativo não ter interferido na manutenção da viabilidade neuronal nos sítios proximais à lesão, sua continuidade prejudicou a viabilidade dos cotos neurais distais, provável causa do atraso na recuperação funcional da marcha.

Development of less invasive neuromuscular electrical stimulation model for motor therapy in rodents

BACKGROUND

Combination therapy is essential for functional repairs of the spinal cord. Rehabilitative therapy can be considered as the key for reorganizing the nervous system after spinal cord regeneration therapy. Functional electrical stimulation has been used as a neuroprosthesis in quadriplegia and can be used for providing rehabilitative therapy to tap the capability for central nervous system reorganization after spinal cord regeneration therapy.

OBJECTIVE

To develop a less invasive muscular electrical stimulation model capable of being combined with spinal cord regeneration therapy especially for motor therapy in the acute stage after spinal cord injury.

METHODS

The tibialis anterior and gastrocnemius motor points were identified in intact anesthetized adult female Fischer rats, and stimulation needle electrodes were percutaneously inserted into these points. Threshold currents for visual twitches were obtained upon stimulation using pulses of 75 or 8 kHz for 200 ms. Biphasic pulse widths of 20, 40, 80, 100, 300, and 500 µs per phase were used to determine strength-duration curves. Using these parameters and previously obtained locomotor electromyogram data, stimulations were performed on bilateral joint muscle pairs to produce reciprocal flexion/extension movements of the ankle for 15 minutes while three-dimensional joint kinematics were assessed.

RESULTS

Rhythmic muscular electrical stimulation with needle electrodes was successfully done, but decreased range of motion (ROM) over time. High-frequency and high-amplitude stimulation was also shown to be effective in alleviating decreases in ROM due to muscle fatigue.

CONCLUSIONS

This model will be useful for investigating the ability of rhythmic muscular electrical stimulation therapy to promote motor recovery, in addition to the efficacy of combining treatments with spinal cord regeneration therapy after spinal cord injuries.

Spinal cord injury and physical activity: preservation of the body

SETTING

Spinal cord injury (SCI) causes devastating loss of function and can result in serious secondary complications. Although significant advances are being made to develop cellular and molecular therapies to promote regeneration, it is important to optimize physical interventions.

OBJECTIVES

The objective of this review was to examine the evidence for the effects of physical rehabilitation strategies on health and fitness, and maintenance of target systems below the level of injury (for example, muscle, bone, circulation).

RESULTS

Exercise appears to be a potent means of achieving these goals, using a variety of strategies.

CONCLUSION

Physical rehabilitation after SCI needs to move beyond the goal of maximizing independence to focus on maintenance of optimum health and fitness as well as maintenance of target system function below the level of injury. Issues requiring further investigation include identification of the optimum dosage of interventions to achieve specific goals, for example, prevention of muscle atrophy and osteoporosis, and development and validation of simple clinical measures to monitor the changes in body composition. Adoption of a classification system for physical interventions and standardized outcome measures would facilitate large-scale observational studies to identify the critical variables contributing to better outcomes.

Effects of combining electrical stimulation with BDNF gene transfer on the regeneration of crushed rat sciatic nerve

BACKGROUND AND AIMS

Various techniques have been investigated to enhance peripheral nerve regeneration including the application of low-intensity electrical stimulation (ES) and the administration of growth factors, especially brain-derived neurotrophic factor (BDNF). The purpose of this study was to investigate the effects of combining short-term (ES) and recombinant adenoviral vector-mediated BDNF (BDNF-Ad) transfer, in comparison to each sole modality, on peripheral nerve regeneration in a rat model with crush-injured sciatic nerve.

METHODS

Sixty male Sprague-Dawley rats (250-300 g) were equally distributed into four groups; the control group, the ES group, the BDNF-Ad group, and the combination group (n = 15 each). A standard crush injury was introduced to the sciatic nerve. The control group received no treatment after injury, the ES group received 30 minutes of low-intensity ES, the BDNF-Ad group received an injection of recombinant BDNF-Ad (concentration = 10(11) pfu/μl, 3 μl/rat) after injury, and the combination group received both ES and BDNF-Ad. The rats were followed-up for 3 weeks.

RESULTS

At the end of the follow-up period, the sciatic function index (ES =-39, BDNF-Ad =-38) and number of the retrogradely labeled sensory neurons were significantly increased in the ES group and the BDNF-Ad group (ES = 326, BDNF-Ad = 264), but not in the combined treatment group, compared to the control group (SFI = -53, retrogradely labeled neurons = 229). Axonal counts were highest in the ES group (7,208 axons), axonal densities in the BDNF group (10,598 axons/mm(2)), and the myelin thickness was greater in both groups as compared to the control group. The combined treatment group showed no signs of superior recovery compared to the other groups.

CONCLUSIONS

Both the ES and the BDNF-Ad treatments were effective techniques enhancing the sciatic nerve regeneration following a crush injury in rats. Nevertheless, the combined treatment with ES and BDNF-Ad produces neither a synergistic effect nor an improvement in this injury model.

The sensitivity of two-dimensional hindlimb joint kinematics analysis in assessing functional recovery in rats after sciatic nerve crush

Walking analysis in the rat is increasingly used to assess functional recovery after peripheral nerve injury. Here we assess the sensitivity and specificity of hindlimb joint kinematics measures during the rat gait early after sciatic nerve crush injury (DEN), after twelve weeks of recovery (REINN) and in sham-operated controls (Sham) using discriminant analysis. The analysis addressed gait spatiotemporal variables and hip, knee and ankle angle and angular velocity measures during the entire walking cycle. In DEN animals, changes affected all studied joints plus spatiotemporal parameters of gait. Both the spatiotemporal and ankle kinematics parameters recovered to normality within twelve weeks. At this time point, some hip and knee kinematics values were still abnormal when compared to sham controls. Discriminant models based on hip, knee and ankle kinematics displayed maximal sensitivity to identify DEN animals. However, the discriminant models based on spatiotemporal and ankle kinematics data showed a poor performance when assigning animals to the REINN and Sham groups. Models using hip and knee kinematics during walking showed the best sensitivity to recognize the reinnervated animals. The model construed on the basis of hip joint kinematics was the one combining highest sensitivity with robustness and high specificity. It is concluded that ankle joint kinematics fails in detecting minor functional deficits after long term recovery from sciatic nerve crush and extending the kinematic analysis during walking to the hip and knee joints improves the sensitivity of this functional test.

Enhancing recovery from peripheral nerve injury using treadmill training

Full functional recovery after traumatic peripheral nerve injury is rare. We postulate three reasons for the poor functional outcome measures observed. Axon regeneration is slow and not all axons participate. Significant misdirection of regenerating axons to reinnervate inappropriate targets occurs. Seemingly permanent changes in neural circuitry in the central nervous system are found to accompany axotomy of peripheral axons. Exercise in the form of modest daily treadmill training impacts all three of these areas. Compared to untrained controls, regenerating axons elongate considerably farther in treadmill trained animals and do so via an autocrine/paracrine neurotrophin signaling pathway. This enhancement of axon regeneration takes place without an increase in the amount of misdirection of regenerating axons found without training. The enhancement also occurs in a sex-dependent manner. Slow continuous training is effective only in males, while more intense interval training is effective only in females. In treadmill trained, but not untrained mice the extent of coverage of axotomized motoneurons is maintained, thus preserving important elements of the spinal circuitry.

The effects of treadmill training on young and mature rats after traumatic peripheral nerve lesion

The purpose of this study was to investigate the possible effects of a treadmill training program on regeneration in young (3-month-old) and mature (13-month-old) rats with sciatic nerve crush using functional, electrophysiological, and morphometric analyses. When compared to both the young and mature untrained injury groups, those groups that underwent a treadmill training showed improved sensorimotor function evaluated by narrow beam test (p<0.04 and p<0.001, respectively), while muscle action potential amplitude was only greater in the young group (p<0.02). The treadmill training program was able to reduce myelinated fiber density in the young group (p<0.001), which appeared to increase after nerve injury (poly-innervation), but decreased with training, which means that the innervation became more functional. The data indicate that treadmill training is able to promote functional, electrophysiological and morphological recovery in young animals. However, in mature animals, improvement was only seen in terms of functional recovery.

Sulodexide prevents peripheral nerve damage in streptozotocin induced diabetic rats

We investigated whether sulodexide has additional protective effects against peripheral nerve damage caused by microvascular dysfunction in a rat model of diabetes. Female Sprague-Dawley (SD) rats were divided into the following 4 groups (n=7-9/group): Normal, Normal+Sulodexide (sulodexide 10mg/kg), diabetic group, and diabetic+Sulodexide (sulodexide 10mg/kg). We assessed current perception threshold, skin blood flow, superoxide dismutase, and proteinuria in experimental rats after oral administration of sulodexide for 20 weeks. We also performed morphometric analysis of sciatic nerves and intraepidermal nerve fibers of the foot. Superoxide dismutase activity in the blood and sciatic nerve were increased significantly after sulodexide treatment in the diabetic group. Current perception threshold was reduced at 2000 Hz (633.3 ± 24.15 vs 741.2 ± 23.5 μA, P<0.05) and skin blood flow was improved (10.90 ± 0.67 vs 8.85 ± 0.49 TPU, P<0.05) in the diabetic+Sulodexide group compared with the diabetic group. The mean myelinated axon area was significantly larger (56.6 ± 2.2 vs 49.8 ± 2.7 μm(2), P<0.05) and the intraepidermal nerve fiber density was significantly less reduced (6.27 ± 0.24 vs 5.40 ± 0.25/mm, P<0.05) in the diabetic+Sulodexide group compared to the diabetic group. Our results demonstrate that sulodexide exhibits protective effects against peripheral nerve damage in a rat experimental model of diabetes. Therefore, these findings suggest that sulodexide is a potential new therapeutic agent for diabetic peripheral neuropathy.

Neurotrophin-4/5 is implicated in the enhancement of axon regeneration produced by treadmill training following peripheral nerve injury

The role of neurotrophin-4/5 (NT-4/5) in the enhancement of axon regeneration in peripheral nerves produced by treadmill training was studied in mice. Common fibular nerves of animals of the H strain of thy-1-YFP mice, in which a subset of axons in peripheral nerves is marked by the presence of yellow fluorescent protein, were cut and surgically repaired using nerve grafts from non-fluorescent mice. Lengths of profiles of fluorescent regenerating axons were measured using optical sections made through whole mounts of harvested nerves. Measurements from mice that had undergone 1 h of daily treadmill training at modest speed (10 m/min) were compared with those of untrained (control) mice. Modest treadmill training resulted in fluorescent axon profiles that were nearly twice as long as controls at 1, 2 and 4 week survival times. Similar enhanced regeneration was found when cut nerves of wild type mice were repaired with grafts from NT-4/5 knockout mice or grafts made acellular by repeated freezing/thawing. No enhancement was produced by treadmill training in NT-4/5 knockout mice, irrespective of the nature of the graft used to repair the cut nerve. Much as had been observed previously for the effects of brief electrical stimulation, the effects of treadmill training on axon regeneration in cut peripheral nerves are independent of changes produced in the distal segment of the cut nerve and depend on the promotion of axon regeneration by changes in NT-4/5 expression by cells in the proximal nerve segment.

Electrical stimulation promotes BDNF expression in spinal cord neurons through Ca(2+)- and Erk-dependent signaling pathways

Brief electrical stimulation has been shown to be effective in promoting neuronal regeneration following peripheral nerve injury. These effects are thought to be mediated largely by the upregulation of the expression of brain-derived neurotrophic factor (BDNF) in spinal cord neurons. However, the molecular mechanisms by which electrical stimulation can promote BDNF expression are not known. The mechanism involved in BDNF expression after electrical stimulation was explored in this study. Immunohistochemistry and Western blotting were used to test BDNF expression. Confocal microscopy was utilized to study intracellular Ca(2+) volume. Immunohistochemistry and Western blotting confirmed that brief electrical stimulation increased BDNF expression in spinal cord neurons both in vivo and in vitro. Treatment of cultured neurons with nifedipine, an inhibitor of voltage-gated calcium channels, significantly reduced the BDNF increase produced by electrical stimulation, and an inhibitor of Erk completely abolished the effect of electrical stimulation. Levels of BDNF expression in the presence of the Erk inhibitor were lower that in unstimulated and untreated controls, indicating that Erk activation is required to maintain baseline levels of BDNF. Confocal microscopy using a Ca(2+)-sensitive fluorochrome revealed that electrical stimulation is accompanied by an increase in intracellular Ca(2+) levels; the increase was partly blocked by nifedipine. These findings argue that electrical stimulation increases BDNF expression in spinal cord neurons by activating a Ca(2+)- and Erk-dependent signaling pathways.

Peripheral nerve repair through multi-luminal biosynthetic implants

Peripheral nerve damage is routinely repaired by autogenic nerve grafting, often leading to less than optimal functional recovery at the expense of healthy donor nerves. Alternative repair strategies use tubular scaffolds to guide the regeneration of damaged nerves, but despite the progress made on improved structural materials for the nerve tubes, functional recovery remains incomplete. We developed a biosynthetic nerve implant (BNI) consisting of a hydrogel-based transparent multichannel scaffold with luminar collagen matrix as a 3-D substrate for nerve repair. Using a rat sciatic nerve injury model we showed axonal regeneration through the BNI to be histologically comparable to the autologous nerve repair. At 10 weeks post-injury, nerve defects repaired with collagen-filled, single lumen tubes formed single nerve cables, while animals that received the multi-luminal BNIs showed multiple nerve cables and the formation of a perineurial-like layer within the available microchannels. Total numbers of myelinated and unmyelinated axons in the BNI were increased 3-fold and 30%, respectively, compared to collagen tubes. The recovery of reflexive movement confirmed the functional regeneration of both motor and sensory neurons. This study supports the use of multi-luminal BNIs as a viable alternative to autografts in the repair of nerve gap injuries.

Passive and active exercise improve regeneration and muscle reinnervation after peripheral nerve injury in the rat

INTRODUCTION

Lesions of peripheral nerves cause loss of motor and sensory function and also lead to hyperreflexia and hyperalgesia. Activity-dependent therapies promote axonal regeneration and functional recovery and may improve sensory-motor coordination and restoration of adequate circuitry at the spinal level.

METHODS

We compared the effects of passive (bicycle) and active (treadmill) exercise on nerve regeneration and modulation of the spinal H reflex after transection and repair of the rat sciatic nerve. Animals were evaluated during 2 months using electrophysiological, functional, and histological methods.

RESULTS

Moderate exercise for 1 hour/day, either active treadmill walking or passive cycling, improved muscle reinnervation, increased the number of regenerated axons in the distal nerve, and reduced the increased excitability of spinal reflexes after nerve lesion.

DISCUSSION

Maintenance of denervated muscle activity and afferent input, by active or passive exercise, may increase trophic factor release to act on regenerating axons and to modulate central neuronal plasticity.

Repair and rehabilitation of plexus and root avulsions in animal models and patients

PURPOSE OF REVIEW

This review will discuss recent progress in experimental and translational research related to surgical repair of proximal nerve root injuries, and emerging potential therapies, which may be combined with replantation surgeries to augment functional outcomes after brachial plexus and cauda equina injuries.

RECENT FINDINGS

Progress in experimental studies of root and peripheral nerve injuries has identified potential candidates for adjunctive therapies, which may be combined with surgical replantation of avulsed roots after brachial plexus and cauda equina injuries. We will discuss recent advances related to adjunctive neuroprotective strategies, neurotrophic factor delivery, and emerging cellular treatment strategies after extensive nerve root trauma. We will also provide an update on electrical stimulation to promote regenerative axonal growth and new insights on the recovery of sensory functions after root injury and repair.

SUMMARY

In the light of recent advances in experimental studies, we envision that future repair of brachial plexus and cauda equina injuries will include spinal cord surgery to restore motor and sensory trajectories and a variety of adjunctive therapies to augment the recovery of neurological function.

Non-surgical therapies for peripheral nerve injury

BACKGROUND

Non-surgical approaches have been developed to enhance nerve recovery, which are complementary to surgery and are an adjunct to the reinnervation process.

SOURCES OF DATA

A search of PubMed, Medline, CINAHL, DH data and Embase databases was performed using the keywords 'peripheral nerve injury' and 'treatment'.

AREAS OF CONTROVERSY

Most of the conservative therapies are focused to control neuropathic pain after nerve tissue damage. Only physical therapy modalities have been studied in humans and their effectiveness is not proved.

GROWING POINTS

Many modalities have been experimented with to promote nerve healing and restore function in animal models and in vitro studies. Despite this, none have been actually translated into clinical practice.

AREAS TIMELY FOR DEVELOPING RESEARCH

The hypotheses proved in animals and in vitro should be translated to human clinical practice.

Timing of applying electrical stimulation is an important factor deciding the success rate and maturity of regenerating rat sciatic nerves

BACKGROUND

The timing of electrical stimulation (ES) after peripheral nerve transection may enhance axonal regeneration and functional recovery.

OBJECTIVE

The authors examined whether percutaneous ES at 1 mA and 2 Hz affects regeneration between the proximal and distal nerve stumps.

METHODS

Four groups of adult rats were subjected to sciatic nerve section followed by repair using silicone rubber conduits across a 10-mm gap. All groups received ES for 15 minutes every other day for 2 weeks. Stimulation was initiated on day 1 following the nerve repair for group A, day 8 for group B, and day 15 for group C. The control group D received no ES.

RESULTS

At 6 weeks after surgery in groups B and C, histological evaluations showed a significantly higher number of regenerated myelinated fibers in the sciatic nerve, and the electrophysiological results showed higher levels of reinnervation with relatively larger mean values of amplitudes, durations, and areas of compound muscle action potentials compared with A and D.

CONCLUSION

A short delay in the onset of ES may improve the recovery of a severe peripheral nerve injury, which should be considered as a way of augmenting rehabilitative approaches.