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Alashram AR. Effects of robotic therapy associated with noninvasive brain stimulation on motor function in individuals with incomplete spinal cord injury: A systematic review of randomized controlled trials. J Spinal Cord Med 2024:1-16. [PMID: 38265422 DOI: 10.1080/10790268.2024.2304921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
CONTEXT Motor deficits are among the most common consequences of incomplete spinal cord injury (SCI). These impairments can affect patients' levels of functioning and quality of life. Combined robotic therapy and non-invasive brain stimulation (NIBS) have been used to improve motor impairments in patients with corticospinal tract lesions. OBJECTIVES To examine the effects of combined robotic therapy and NIBS on motor function post incomplete SCI. METHODS PubMed, SCOPUS, MEDLINE, PEDro, Web of Science, REHABDATA, CINAHL, and EMBASE were searched from inception until July 2023. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the selected studies quality. RESULTS Of 557 studies, five randomized trials (n = 122), with 25% of participants being females, were included in this review. The PEDro scores ranged from eight to nine, with a median score of nine. There were variations in treatment protocols and outcome measures, resulting in heterogeneous findings. The findings showed revealed evidence for the impacts of combined robotic therapy and NIBS on motor function in individuals with incomplete SCI. CONCLUSIONS Combined robotic training and NIBS may be safe for individuals with incomplete SCI. The existing evidence concerning its effects on motor outcomes in individuals with SCI is limited. Further experimental studies are needed to understand the effects of combined robotic training and NIBS on motor impairments in SCI populations.
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Affiliation(s)
- Anas R Alashram
- Department of Physiotherapy, Middle East University, Amman, Jordan
- Applied Science Research Center, Applied Science Private University, Amman, Jordan
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
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Skiadopoulos A, Famodimu GO, Solomon SK, Agarwal P, Harel NY, Knikou M. Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial. Trials 2023; 24:145. [PMID: 36841773 PMCID: PMC9960224 DOI: 10.1186/s13063-023-07193-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/20/2023] [Indexed: 02/27/2023] Open
Abstract
BACKGROUND The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown. METHODS Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30 min of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30 min of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder, and sexual function are taken. DISCUSSION The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because, in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach. TRIAL REGISTRATION ClinicalTrials.gov NCT04807764 . Registered on March 19, 2021.
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Affiliation(s)
- Andreas Skiadopoulos
- grid.254498.60000 0001 2198 5185Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY USA ,grid.254498.60000 0001 2198 5185Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY USA
| | - Grace O. Famodimu
- Spinal Cord Damage Research Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY USA
| | - Shammah K. Solomon
- grid.254498.60000 0001 2198 5185Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY USA ,grid.254498.60000 0001 2198 5185Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY USA
| | - Parul Agarwal
- grid.59734.3c0000 0001 0670 2351Population Health Science & Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, Manhattan, NY USA
| | - Noam Y. Harel
- Spinal Cord Damage Research Center, James J. Peters Department of Veterans Affairs Medical Center, Bronx, NY USA ,grid.59734.3c0000 0001 0670 2351Population Health Science & Policy, Institute for Health Care Delivery Science, Icahn School of Medicine at Mount Sinai, Manhattan, NY USA
| | - Maria Knikou
- Klab4Recovery Research Program, The City University of New York, College of Staten Island, Staten Island, NY, USA. .,Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY, USA. .,PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of The City University of New York and College of Staten Island, Manhattan & Staten Island, NY, USA.
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Skiadopoulos A, Famodimu GO, Solomon SK, Agrawal P, Harel NY, Knikou M. Priming locomotor training with transspinal stimulation in people with spinal cord injury: study protocol of a randomized clinical trial. RESEARCH SQUARE 2023:rs.3.rs-2527617. [PMID: 36824823 PMCID: PMC9949167 DOI: 10.21203/rs.3.rs-2527617/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background The seemingly simple tasks of standing and walking require continuous integration of complex spinal reflex circuits between descending motor commands and ascending sensory inputs. Spinal cord injury greatly impairs standing and walking ability, but both improve with locomotor training. However, even after multiple locomotor training sessions, abnormal muscle activity and coordination persist. Thus, locomotor training alone cannot fully optimize the neuronal plasticity required to strengthen the synapses connecting the brain, spinal cord, and local circuits and potentiate neuronal activity based on need. Transcutaneous spinal cord (transspinal) stimulation alters motoneuron excitability over multiple segments by bringing motoneurons closer to threshold, a prerequisite for effectively promoting spinal locomotor network neuromodulation and strengthening neural connectivity of the injured human spinal cord. Importantly, whether concurrent treatment with transspinal stimulation and locomotor training maximizes motor recovery after spinal cord injury is unknown. Methods Forty-five individuals with chronic spinal cord injury are receiving 40 sessions of robotic gait training primed with 30 Hz transspinal stimulation at the Thoracic 10 vertebral level. Participants are randomized to receive 30-minutes of active or sham transspinal stimulation during standing or active transspinal stimulation while supine followed by 30-minutes of robotic gait training. Over the course of locomotor training, the body weight support, treadmill speed, and leg guidance force are adjusted as needed for each participant based on absence of knee buckling during the stance phase and toe dragging during the swing phase. At baseline and after completion of all therapeutic sessions, neurophysiological recordings registering corticospinal and spinal neural excitability changes along with clinical assessment measures of standing and walking, and autonomic function via questionnaires regarding bowel, bladder and sexual function are taken. Discussion The results of this mechanistic randomized clinical trial will demonstrate that tonic transspinal stimulation strengthens corticomotoneuronal connectivity and dynamic neuromodulation through posture-dependent corticospinal and spinal neuroplasticity. We anticipate that this mechanistic clinical trial will greatly impact clinical practice because in real-world clinical settings, noninvasive transspinal stimulation can be more easily and widely implemented than invasive epidural stimulation. Additionally, by applying multiple interventions to accelerate motor recovery, we are employing a treatment regimen that reflects a true clinical approach. Trial registration ClinicalTrials.gov: NCT04807764; Registered on March 19, 2021.
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Affiliation(s)
| | | | | | - Parul Agrawal
- Icahn School of Medicine at Mount Sinai Department of Population Health Science and Policy
| | - Noam Y Harel
- James J Peters VAMC: James J Peters VA Medical Center
| | - Maria Knikou
- College of Staten Island School of Health Sciences
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Pulverenti TS, Zaaya M, Grabowski E, Grabowski M, Knikou M. Brain and spinal cord paired stimulation coupled with locomotor training facilitates motor output in human spinal cord injury. Front Neurol 2022; 13:1000940. [PMID: 36313489 PMCID: PMC9612520 DOI: 10.3389/fneur.2022.1000940] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022] Open
Abstract
Combined interventions for neuromodulation leading to neurorecovery have gained great attention by researchers to resemble clinical rehabilitation approaches. In this randomized clinical trial, we established changes in the net output of motoneurons innervating multiple leg muscles during stepping when transcranial magnetic stimulation (TMS) of the primary motor cortex was paired with transcutaneous spinal (transspinal) stimulation over the thoracolumbar region during locomotor training. TMS was delivered before (TMS-transspinal) or after (transspinal-TMS) transspinal stimulation during the stance phase of the less impaired leg. Ten individuals with chronic incomplete or complete SCI received at least 20 sessions of training. Each session consisted of 240 paired stimuli delivered over 10-min blocks for 1 h during robotic assisted step training on a motorized treadmill. Body weight support, leg guidance force and treadmill speed were adjusted based on each subject's ability to step without knee buckling or toe dragging. Most transspinal evoked potentials (TEPs) recorded before and after each intervention from ankle and knee muscles during assisted stepping were modulated in a phase-dependent pattern. Transspinal-TMS and locomotor training affected motor neuron output of knee and ankle muscles with ankle TEPs to be modulated in a phase-dependent manner. TMS-transspinal and locomotor training increased motor neuron output for knee but not for ankle muscles. Our results support that targeted brain and spinal cord stimulation alters responsiveness of neurons over multiple spinal segments in people with chronic SCI. Noninvasive stimulation of the brain and spinal cord along with locomotor training is a novel neuromodulation method that can become a promising modality for rehabilitation in humans after SCI.
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Affiliation(s)
- Timothy S. Pulverenti
- Klab4Recovery Research Program, The City University of New York, New York, NY, United States
| | - Morad Zaaya
- Klab4Recovery Research Program, The City University of New York, New York, NY, United States
| | - Ewelina Grabowski
- PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of the City University of New York and College of Staten Island, New York, NY, United States
| | - Monika Grabowski
- PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of the City University of New York and College of Staten Island, New York, NY, United States
| | - Maria Knikou
- Klab4Recovery Research Program, The City University of New York, New York, NY, United States,PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of the City University of New York and College of Staten Island, New York, NY, United States,Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States,*Correspondence: Maria Knikou
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Brain and spinal cord paired stimulation coupled with locomotor training affects polysynaptic flexion reflex circuits in human spinal cord injury. Exp Brain Res 2022; 240:1687-1699. [PMID: 35513720 DOI: 10.1007/s00221-022-06375-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 04/15/2022] [Indexed: 12/19/2022]
Abstract
Neurorecovery from locomotor training is well established in human spinal cord injury (SCI). However, neurorecovery resulting from combined interventions has not been widely studied. In this randomized clinical trial, we established the tibialis anterior (TA) flexion reflex modulation pattern when transcranial magnetic stimulation (TMS) of the primary motor cortex was paired with transcutaneous spinal cord (transspinal) stimulation over the thoracolumbar region during assisted step training. Single pulses of TMS were delivered either before (TMS-transspinal) or after (transspinal-TMS) transspinal stimulation during the stance phase of the less impaired leg. Eight individuals with chronic incomplete or complete SCI received at least 20 sessions of paired stimulation during assisted step training. Each session consisted of 240 paired stimuli delivered over 10-min blocks for 1 h during robotic-assisted step training with the Lokomat6 Pro®. Body weight support, leg guidance force and treadmill speed were adjusted based on each participant's ability to step without knee buckling or toe dragging. Both the early and late TA flexion reflex remained unaltered after TMS-transspinal and locomotor training. In contrast, the early and late TA flexion reflexes were significantly depressed during stepping after transspinal-TMS and locomotor training. Reflex changes occurred at similar slopes and intercepts before and after training. Our findings support that targeted brain and spinal cord stimulation coupled with locomotor training reorganizes the function of flexion reflex pathways, which are a part of locomotor networks, in humans with varying levels of sensorimotor function after SCI.Trial registration number NCT04624607; Registered on November 12, 2020.
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Balbinot G, Joner Wiest M, Li G, Pakosh M, Cesar Furlan J, Kalsi-Ryan S, Zariffa J. The use of surface EMG in neurorehabilitation following traumatic spinal cord injury: a scoping review. Clin Neurophysiol 2022; 138:61-73. [DOI: 10.1016/j.clinph.2022.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/06/2022] [Accepted: 02/27/2022] [Indexed: 11/03/2022]
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Alashram AR, Annino G, Padua E. Robot-assisted gait training in individuals with spinal cord injury: A systematic review for the clinical effectiveness of Lokomat. J Clin Neurosci 2021; 91:260-269. [PMID: 34373038 DOI: 10.1016/j.jocn.2021.07.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/04/2021] [Accepted: 07/16/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) is a critical medical condition that causes numerous impairments leading to accompanying disability. Robotic-assisted gait training (RAGT) offers many advantages, including the capability to increase the intensity and total duration of training while maintaining a physiological gait pattern. The effects of the RAGT 'Lokomat' on various impairments following SCI remain unclear. OBJECTIVES This review was conducted to examine the impacts of the RAGT 'Lokomat' on the impairments following SCI. METHODS We searched PubMed, SCOPUS, PEDro, REHABDATA, MEDLINE, EMBASE, and web of science from inception to January 2021. Experimental studies examining the effects of the Lokomat on the impairments following incomplete SCI were selected. The methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. RESULTS Sixteen studies were met the inclusion criteria. Thirteen were randomized controlled trials, two were clinical trials, and one was a pilot study. The scores on the PEDro scale ranged from two to eight, with a median score of six. The results showed evidence for the beneficial effects of the Lokomat on many motor impairments following incomplete SCI. CONCLUSIONS The Lokomat may improve gait speed, walking distance, strength, range of motion, and mobility after incomplete SCI. There is insufficient evidence for the effect of the Lokomat on balance, depression, cardiorespiratory fitness, and quality of life. The effects of the Lokomat on the lower extremity spasticity were limited.
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Affiliation(s)
- Anas R Alashram
- Department of Physiotherapy, Isra University, Amman, Jordan.
| | - Giuseppe Annino
- Department of Medicine Systems, University of Rome "Tor Vergata", Rome, Italy
| | - Elvira Padua
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy
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Zaaya M, Pulverenti TS, Knikou M. Transspinal stimulation and step training alter function of spinal networks in complete spinal cord injury. Spinal Cord Ser Cases 2021; 7:55. [PMID: 34218255 DOI: 10.1038/s41394-021-00421-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 11/09/2022] Open
Abstract
STUDY DESIGN Pilot study (case series). OBJECTIVE The objective of this study was to establish spinal neurophysiological changes following high-frequency transspinal stimulation during robot-assisted step training in individuals with chronic motor complete spinal cord injury (SCI). SETTING University research laboratory (Klab4Recovery). METHODS Four individuals with motor complete SCI received an average of 18 sessions of transspinal stimulation over the thoracolumbar region with a pulse train at 333 Hz during robotic-assisted step training. Each session lasted ~1 h, with an average of 240 stimulations delivered during each training session. Before and after the combined intervention, we evaluated the amplitude modulation of the long-latency tibialis anterior (TA) flexion reflex and transspinal evoked potentials (TEP) recorded from flexors and extensors during assisted stepping, and the TEP recruitment curves at rest. RESULTS The long-latency TA flexion reflex was depressed in all phases of the step cycle and the phase-dependent amplitude modulation of TEPs was altered during assisted stepping, while spinal motor output based on TEP recruitment curves was increased after the combined intervention. CONCLUSION This is the first study documenting noninvasive transspinal stimulation coupled with locomotor training depresses flexion reflex excitability and concomitantly increases motoneuron output over multiple spinal segments for both flexors and extensors in people with motor complete SCI. While both transspinal stimulation and locomotor training may act via similar activity-dependent neuroplasticity mechanisms, combined interventions for rehabilitation of neurological disorders has not been systematically assessed. Our current findings support locomotor training induced neuroplasticity may be augmented with transspinal stimulation.
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Affiliation(s)
- Morad Zaaya
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, New York, NY, USA
| | - Timothy S Pulverenti
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, New York, NY, USA.
| | - Maria Knikou
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, New York, NY, USA.,PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of The City University of New York, New York, NY, USA
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Pulverenti TS, Zaaya M, Grabowski M, Grabowski E, Islam MA, Li J, Murray LM, Knikou M. Neurophysiological Changes After Paired Brain and Spinal Cord Stimulation Coupled With Locomotor Training in Human Spinal Cord Injury. Front Neurol 2021; 12:627975. [PMID: 34040572 PMCID: PMC8141587 DOI: 10.3389/fneur.2021.627975] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/01/2021] [Indexed: 11/13/2022] Open
Abstract
Neurophysiological changes that involve activity-dependent neuroplasticity mechanisms via repeated stimulation and locomotor training are not commonly employed in research even though combination of interventions is a common clinical practice. In this randomized clinical trial, we established neurophysiological changes when transcranial magnetic stimulation (TMS) of the motor cortex was paired with transcutaneous thoracolumbar spinal (transspinal) stimulation in human spinal cord injury (SCI) delivered during locomotor training. We hypothesized that TMS delivered before transspinal (TMS-transspinal) stimulation promotes functional reorganization of spinal networks during stepping. In this protocol, TMS-induced corticospinal volleys arrive at the spinal cord at a sufficient time to interact with transspinal stimulation induced depolarization of alpha motoneurons over multiple spinal segments. We further hypothesized that TMS delivered after transspinal (transspinal-TMS) stimulation induces less pronounced effects. In this protocol, transspinal stimulation is delivered at time that allows transspinal stimulation induced action potentials to arrive at the motor cortex and affect descending motor volleys at the site of their origin. Fourteen individuals with motor incomplete and complete SCI participated in at least 25 sessions. Both stimulation protocols were delivered during the stance phase of the less impaired leg. Each training session consisted of 240 paired stimuli delivered over 10-min blocks. In transspinal-TMS, the left soleus H-reflex increased during the stance-phase and the right soleus H-reflex decreased at mid-swing. In TMS-transspinal no significant changes were found. When soleus H-reflexes were grouped based on the TMS-targeted limb, transspinal-TMS and locomotor training promoted H-reflex depression at swing phase, while TMS-transspinal and locomotor training resulted in facilitation of the soleus H-reflex at stance phase of the step cycle. Furthermore, both transspinal-TMS and TMS-transspinal paired-associative stimulation (PAS) and locomotor training promoted a more physiological modulation of motor activity and thus depolarization of motoneurons during assisted stepping. Our findings support that targeted non-invasive stimulation of corticospinal and spinal neuronal pathways coupled with locomotor training produce neurophysiological changes beneficial to stepping in humans with varying deficits of sensorimotor function after SCI.
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Affiliation(s)
- Timothy S Pulverenti
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Morad Zaaya
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Monika Grabowski
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Ewelina Grabowski
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Md Anamul Islam
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Jeffrey Li
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Lynda M Murray
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States
| | - Maria Knikou
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, New York, NY, United States.,Ph.D. Program in Biology and Collaborative Neuroscience Program, Graduate Center of the City University of New York and College of Staten Island, New York, NY, United States
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Shon A, Brakel K, Hook M, Park H. Fully Implantable Plantar Cutaneous Augmentation System for Rats Using Closed-loop Electrical Nerve Stimulation. IEEE TRANSACTIONS ON BIOMEDICAL CIRCUITS AND SYSTEMS 2021; 15:326-338. [PMID: 33861705 DOI: 10.1109/tbcas.2021.3072894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Plantar cutaneous feedback plays an important role in stable and efficient gait, by modulating the activity of ankle dorsi- and plantar-flexor muscles. However, central and peripheral nervous system trauma often decrease plantar cutaneous feedback and/or interneuronal excitability in processing the plantar cutaneous feedback. In this study, we tested a fully implantable neural recording and stimulation system augmenting plantar cutaneous feedback. Electromyograms were recorded from the medial gastrocnemius muscle for stance phase detection, while biphasic stimulation pulses were applied to the distal-tibial nerve during the stance phase to augment plantar cutaneous feedback. A Bluetooth low energy and a Qi-standard inductive link were adopted for wireless communication and wireless charging, respectively. To test the operation of the system, one intact rat walked on a treadmill with the electrical system implanted into its back. Leg kinematics were recorded to identify the stance phase. Stimulation was applied, with a 250-ms onset delay from stance onset and 200-ms duration, resulting in the onset at 47.58 ± 2.82% of stance phase and the offset at 83.49 ± 4.26% of stance phase (Mean ± SEM). The conduction velocity of the compound action potential (31.2 m/s and 41.6 m/s at 1·T and 2·T, respectively) suggests that the evoked action potential was characteristic of an afferent volley for cutaneous feedback. We also demonstrated successful wireless charging and system reset functions. The experimental results suggest that the presented implantable system can be a valuable neural interface tool to investigate the effect of plantar cutaneous augmentation on gait in a rat model.
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11
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Islam MA, Pulverenti TS, Knikou M. Neuronal Actions of Transspinal Stimulation on Locomotor Networks and Reflex Excitability During Walking in Humans With and Without Spinal Cord Injury. Front Hum Neurosci 2021; 15:620414. [PMID: 33679347 PMCID: PMC7930001 DOI: 10.3389/fnhum.2021.620414] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 01/25/2021] [Indexed: 12/03/2022] Open
Abstract
This study investigated the neuromodulatory effects of transspinal stimulation on soleus H-reflex excitability and electromyographic (EMG) activity during stepping in humans with and without spinal cord injury (SCI). Thirteen able-bodied adults and 5 individuals with SCI participated in the study. EMG activity from both legs was determined for steps without, during, and after a single-pulse or pulse train transspinal stimulation delivered during stepping randomly at different phases of the step cycle. The soleus H-reflex was recorded in both subject groups under control conditions and following single-pulse transspinal stimulation at an individualized exactly similar positive and negative conditioning-test interval. The EMG activity was decreased in both subject groups at the steps during transspinal stimulation, while intralimb and interlimb coordination were altered only in SCI subjects. At the steps immediately after transspinal stimulation, the physiological phase-dependent EMG modulation pattern remained unaffected in able-bodied subjects. The conditioned soleus H-reflex was depressed throughout the step cycle in both subject groups. Transspinal stimulation modulated depolarization of motoneurons over multiple segments, limb coordination, and soleus H-reflex excitability during assisted stepping. The soleus H-reflex depression may be the result of complex spinal inhibitory interneuronal circuits activated by transspinal stimulation and collision between orthodromic and antidromic volleys in the peripheral mixed nerve. The soleus H-reflex depression by transspinal stimulation suggests a potential application for normalization of spinal reflex excitability after SCI.
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Affiliation(s)
- Md. Anamul Islam
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY, United States
| | - Timothy S. Pulverenti
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY, United States
| | - Maria Knikou
- Klab4Recovery Research Laboratory, Department of Physical Therapy, College of Staten Island, The City University of New York, Staten Island, NY, United States
- PhD Program in Biology and Collaborative Neuroscience Program, Graduate Center of the City University of New York and College of Staten Island, New York, NY, United States
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Alajam R, Alqahtani AS, Liu W. Effect of Body Weight-Supported Treadmill Training on Cardiovascular and Pulmonary Function in People With Spinal Cord Injury: A Systematic Review. Top Spinal Cord Inj Rehabil 2020; 25:355-369. [PMID: 31844387 DOI: 10.1310/sci2504-355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective: To assess the current evidence with regard to the effects of body weight-supported treadmill training (BWSTT) on cardiovascular and pulmonary function in people with spinal cord injury (SCI) with a focus on outcomes of heart rate (HR), blood pressure (BP), and respiratory parameters. Methods: A systematic literature search was conducted through MEDLINE/PubMed, the Cumulative Index to Nursing and Allied Health Literature, and Physiotherapy Evidence Database. Clinical trials involving adults with SCI and focusing on the effects of BWSTT on HR, BP, and respiratory measurements were included. The quality of included studies was assessed using the Downs and Black scale. The level of evidence of each study was identified using the Spinal Cord Injury Rehabilitation Evidence system. Results: Nine studies that met inclusion criteria were evaluated and included in this review. Overall, the quality index of all included studies was low. All studies scored less than 21 out of 28 on the Downs and Black scale. The level of evidence varied from level 2 to level 4. Level 4 evidence supports the use of BWSTT to decrease resting and exercise HR and improve heart rate variability. The use of BWSTT to improve respiratory parameters after SCI is supported by one study with level 2 evidence. The evidence that supports the use of BWSTT to improve resting BP is inconclusive. Conclusion: There has been low to moderate evidence to support the use of BWSTT in individuals with SCI to improve cardiovascular and pulmonary health. Future randomized controlled trials are needed to investigate the effect of BWSTT on cardiovascular and pulmonary function in people with SCI and compare BWSTT to other physical rehabilitation interventions.
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Affiliation(s)
- Ramzi Alajam
- Jazan University Faculty of Applied Medical Science, Jazan, Saudi Arabia.,University of Kansas Medical Center, Department of Physical Therapy and Rehabilitation Science, Kansas City, Kansas
| | | | - Wen Liu
- University of Kansas Medical Center, Department of Physical Therapy and Rehabilitation Science, Kansas City, Kansas
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Repeated transspinal stimulation decreases soleus H-reflex excitability and restores spinal inhibition in human spinal cord injury. PLoS One 2019; 14:e0223135. [PMID: 31557238 PMCID: PMC6762874 DOI: 10.1371/journal.pone.0223135] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/14/2019] [Indexed: 12/12/2022] Open
Abstract
Transcutaneous spinal cord or transspinal stimulation over the thoracolumbar enlargement, the spinal location of motoneurons innervating leg muscles, modulates neural circuits engaged in the control of movement. The extent to which daily sessions (e.g. repeated) of transspinal stimulation affects soleus H-reflex excitability in individuals with chronic spinal cord injury (SCI) remains largely unknown. In this study, we established the effects of repeated cathodal transspinal stimulation on soleus H-reflex excitability and spinal inhibition in individuals with and without chronic SCI. Ten SCI and 10 healthy control subjects received monophasic transspinal stimuli of 1-ms duration at 0.2 Hz at subthreshold and suprathreshold intensities of the right soleus transspinal evoked potential (TEP). SCI subjects received an average of 16 stimulation sessions, while healthy control subjects received an average of 10 stimulation sessions. Before and one or two days post intervention, we used the soleus H reflex to assess changes in motoneuron recruitment, homosynaptic depression following single tibial nerve stimuli delivered at 0.1, 0.125, 0.2, 0.33 and 1.0 Hz, and postactivation depression following paired tibial nerve stimuli at the interstimulus intervals of 60, 100, 300, and 500 ms. Soleus H-reflex excitability was decreased in both legs in motor incomplete and complete SCI but not in healthy control subjects. Soleus H-reflex homosynaptic and postactivation depression was present in motor incomplete and complete SCI but was of lesser strength to that observed in healthy control subjects. Repeated transspinal stimulation increased homosynaptic depression in all SCI subjects and remained unaltered in healthy controls. Postactivation depression remained unaltered in all subject groups. Lastly, transspinal stimulation decreased the severity of spasms and ankle clonus. The results indicate decreased reflex hyperexcitability and recovery of spinal inhibitory control in the injured human spinal cord with repeated transspinal stimulation. Transspinal stimulation is a noninvasive neuromodulation method for restoring spinally-mediated afferent reflex actions after SCI in humans.
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Modulation of soleus stretch reflexes during walking in people with chronic incomplete spinal cord injury. Exp Brain Res 2019; 237:2461-2479. [PMID: 31309252 PMCID: PMC6751142 DOI: 10.1007/s00221-019-05603-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/08/2019] [Indexed: 12/28/2022]
Abstract
In people with spasticity due to chronic incomplete spinal cord injury (SCI), it has been presumed that the abnormal stretch reflex activity impairs gait. However, locomotor stretch reflexes across all phases of walking have not been investigated in people with SCI. Thus, to understand modulation of stretch reflex excitability during spastic gait, we investigated soleus stretch reflexes across the entire gait cycle in nine neurologically normal participants and nine participants with spasticity due to chronic incomplete SCI (2.5–11 year post-injury). While the participant walked on the treadmill at his/her preferred speed, unexpected ankle dorsiflexion perturbations (6° at 250°/s) were imposed every 4–6 steps. The soleus H-reflex was also examined. In participants without SCI, spinal short-latency “M1”, spinal medium latency “M2”, and long-latency “M3” were clearly modulated throughout the step cycle; the responses were largest in the mid-stance and almost completely suppressed during the stance-swing transition and swing phases. In participants with SCI, M1 and M2 were abnormally large in the mid–late-swing phase, while M3 modulation was similar to that in participants without SCI. The H-reflex was also large in the mid–late-swing phase. Elicitation of H-reflex and stretch reflexes in the late swing often triggered clonus and affected the soleus activity in the following stance. In individuals without SCI, moderate positive correlation was found between H-reflex and stretch reflex sizes across the step cycle, whereas in participants with SCI, such correlation was weak to non-existing, suggesting that H-reflex investigation would not substitute for stretch reflex investigation in individuals after SCI.
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Filipp ME, Travis BJ, Henry SS, Idzikowski EC, Magnuson SA, Loh MY, Hellenbrand DJ, Hanna AS. Differences in neuroplasticity after spinal cord injury in varying animal models and humans. Neural Regen Res 2019; 14:7-19. [PMID: 30531063 PMCID: PMC6263009 DOI: 10.4103/1673-5374.243694] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rats have been the primary model to study the process and underlying mechanisms of recovery after spinal cord injury. Two weeks after a severe spinal cord contusion, rats can regain weight-bearing abilities without therapeutic interventions, as assessed by the Basso, Beattie and Bresnahan locomotor scale. However, many human patients suffer from permanent loss of motor function following spinal cord injury. While rats are the most understood animal model, major differences in sensorimotor pathways between quadrupeds and bipeds need to be considered. Understanding the major differences between the sensorimotor pathways of rats, non-human primates, and humans is a start to improving targets for treatments of human spinal cord injury. This review will discuss the neuroplasticity of the brain and spinal cord after spinal cord injury in rats, non-human primates, and humans. A brief overview of emerging interventions to induce plasticity in humans with spinal cord injury will also be discussed.
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Affiliation(s)
- Mallory E Filipp
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Benjamin J Travis
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Stefanie S Henry
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Emma C Idzikowski
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Sarah A Magnuson
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | - Megan Yf Loh
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
| | | | - Amgad S Hanna
- Department of Neurological Surgery, University of Wisconsin, Madison, WI, USA
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Loy K, Schmalz A, Hoche T, Jacobi A, Kreutzfeldt M, Merkler D, Bareyre FM. Enhanced Voluntary Exercise Improves Functional Recovery following Spinal Cord Injury by Impacting the Local Neuroglial Injury Response and Supporting the Rewiring of Supraspinal Circuits. J Neurotrauma 2018; 35:2904-2915. [PMID: 29943672 DOI: 10.1089/neu.2017.5544] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Recent reports suggest that rehabilitation measures that increase physical activity of patients can improve functional outcome after incomplete spinal cord injuries (iSCI). To investigate the structural basis of exercise-induced recovery, we examined local and remote consequences of voluntary wheel training in spinal cord injured female mice. In particular, we explored how enhanced voluntary exercise influences the neuronal and glial response at the lesion site as well as the rewiring of supraspinal tracts after iSCI. We chose voluntary exercise initiated by providing mice with free access to running wheels over "forced overuse" paradigms because the latter, at least in some cases, can lead to worsening of functional outcomes after SCI. Our results show that mice extensively use their running wheels not only before but also after injury reaching their pre-lesion exercise levels within five days after injury. Enhanced voluntary exercise improved their overall and skilled motor function after injury. In addition, exercising mice started to recover earlier and reached better sustained performance levels. These improvements in motor performance are accompanied by early changes of axonal and glial response at the lesion site and persistent enhancements of the rewiring of supraspinal connections that resulted in a strengthening of both indirect and direct inputs to lumbar motoneurons.
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Affiliation(s)
- Kristina Loy
- 1 Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany.,2 Biomedical Center Munich (BMC), Faculty of Medicine, LMU Munich, Planegg-Martinsried, Germany.,3 Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universitaet Munich, Planegg-Martinsried, Germany
| | - Anja Schmalz
- 1 Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany.,2 Biomedical Center Munich (BMC), Faculty of Medicine, LMU Munich, Planegg-Martinsried, Germany
| | - Tobias Hoche
- 1 Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany.,2 Biomedical Center Munich (BMC), Faculty of Medicine, LMU Munich, Planegg-Martinsried, Germany
| | - Anne Jacobi
- 1 Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany.,2 Biomedical Center Munich (BMC), Faculty of Medicine, LMU Munich, Planegg-Martinsried, Germany
| | - Mario Kreutzfeldt
- 4 Departement of Pathology et Immunology, CMU, University of Geneva, Rue Michel-Servet, Geneva, Switzerland
| | - Doron Merkler
- 4 Departement of Pathology et Immunology, CMU, University of Geneva, Rue Michel-Servet, Geneva, Switzerland
| | - Florence M Bareyre
- 1 Institute of Clinical Neuroimmunology, University Hospital, LMU Munich, Munich, Germany.,2 Biomedical Center Munich (BMC), Faculty of Medicine, LMU Munich, Planegg-Martinsried, Germany.,5 Munich Cluster of Systems Neurology (SyNergy), Munich, Germany
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17
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Martinez SA, Nguyen ND, Bailey E, Doyle-Green D, Hauser HA, Handrakis JP, Knezevic S, Marett C, Weinman J, Romero AF, Santiago TM, Yang AH, Yung L, Asselin PK, Weir JP, Kornfeld SD, Bauman WA, Spungen AM, Harel NY. Multimodal cortical and subcortical exercise compared with treadmill training for spinal cord injury. PLoS One 2018; 13:e0202130. [PMID: 30092092 PMCID: PMC6084979 DOI: 10.1371/journal.pone.0202130] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 06/25/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND PURPOSE Spared fibers after spinal cord injury (SCI) tend to consist predominantly of subcortical circuits that are not under volitional (cortical) control. We aim to improve function after SCI by using targeted physical exercises designed to simultaneously stimulate cortical and spared subcortical neural circuits. METHODS Participants with chronic motor-incomplete SCI enrolled in a single-center, prospective interventional crossover study. Participants underwent 48 sessions each of weight-supported robotic-assisted treadmill training and a novel combination of balance and fine hand exercises, in randomized order, with a 6-week washout period. Change post-intervention was measured for lower extremity motor score, soleus H-reflex facilitation; seated balance function; ambulation; spasticity; and pain. RESULTS Only 9 of 21 enrolled participants completed both interventions. Thirteen participants completed at least one intervention. Although there were no statistically significant differences, multimodal training tended to increase short-interval H-reflex facilitation, whereas treadmill training tended to improve dynamic seated balance. DISCUSSION The low number of participants who completed both phases of the crossover intervention limited the power of this study to detect significant effects. Other potential explanations for the lack of significant differences with multimodal training could include insufficient engagement of lower extremity motor cortex using skilled upper extremity exercises; and lack of skill transfer from upright postural stability during multimodal training to seated dynamic balance during testing. To our knowledge, this is the first published study to report seated posturography outcomes after rehabilitation interventions in individuals with SCI. CONCLUSION In participants with chronic incomplete SCI, a novel mix of multimodal exercises incorporating balance exercises with skilled upper extremity exercises showed no benefit compared to an active control program of body weight-supported treadmill training. To improve participant retention in long-term rehabilitation studies, subsequent trials would benefit from a parallel group rather than crossover study design.
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Affiliation(s)
| | - Nhuquynh D. Nguyen
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Eric Bailey
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Denis Doyle-Green
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Henry A. Hauser
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - John P. Handrakis
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- New York Institute of Technology, Old Westbury, New York, United States of America
| | - Steven Knezevic
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Casey Marett
- New York Institute of Technology, Old Westbury, New York, United States of America
| | - Jennifer Weinman
- New York Institute of Technology, Old Westbury, New York, United States of America
| | - Angelica F. Romero
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Tiffany M. Santiago
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Ajax H. Yang
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Lok Yung
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Pierre K. Asselin
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - Joseph P. Weir
- University of Kansas, Lawrence, Kansas, United States of America
| | - Stephen D. Kornfeld
- James J. Peters VA Medical Center, Bronx, New York, United States of America
| | - William A. Bauman
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Ann M. Spungen
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Noam Y. Harel
- James J. Peters VA Medical Center, Bronx, New York, United States of America
- Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
- * E-mail:
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18
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Holanda LJ, Silva PMM, Amorim TC, Lacerda MO, Simão CR, Morya E. Robotic assisted gait as a tool for rehabilitation of individuals with spinal cord injury: a systematic review. J Neuroeng Rehabil 2017; 14:126. [PMID: 29202845 PMCID: PMC5715997 DOI: 10.1186/s12984-017-0338-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 11/23/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Spinal cord injury (SCI) is characterized by a total or partial deficit of sensory and motor pathways. Impairments of this injury compromise muscle recruitment and motor planning, thus reducing functional capacity. SCI patients commonly present psychological, intestinal, urinary, osteomioarticular, tegumentary, cardiorespiratory and neural alterations that aggravate in chronic phase. One of the neurorehabilitation goals is the restoration of these abilities by favoring improvement in the quality of life and functional independence. Current literature highlights several benefits of robotic gait therapies in SCI individuals. OBJECTIVES The purpose of this study was to compare the robotic gait devices, and systematize the scientific evidences of these devices as a tool for rehabilitation of SCI individuals. METHODS A systematic review was carried out in which relevant articles were identified by searching the following databases: Cochrane Library, PubMed, PEDro and Capes Periodic. Two authors selected the articles which used a robotic device for rehabilitation of spinal cord injury. RESULTS Databases search found 2941 articles, 39 articles were included due to meet the inclusion criteria. The robotic devices presented distinct features, with increasing application in the last years. Studies have shown promising results regarding the reduction of pain perception and spasticity level; alteration of the proprioceptive capacity, sensitivity to temperature, vibration, pressure, reflex behavior, electrical activity at muscular and cortical level, classification of the injury level; increase in walking speed, step length and distance traveled; improvements in sitting posture, intestinal, cardiorespiratory, metabolic, tegmental and psychological functions. CONCLUSIONS This systematic review shows a significant progress encompassing robotic devices as an innovative and effective therapy for the rehabilitation of individuals with SCI.
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Affiliation(s)
- Ledycnarf J Holanda
- Neuroengineering Program, Edmond and Lily Safra International Neuroscience Institute, Santos Dumont Institute, Rodovia RN 160, Km 03, 3001 Distrito Jundiaí, Macaíba, 59280-000, Brazil.
| | - Patrícia M M Silva
- Neuroengineering Program, Edmond and Lily Safra International Neuroscience Institute, Santos Dumont Institute, Rodovia RN 160, Km 03, 3001 Distrito Jundiaí, Macaíba, 59280-000, Brazil
| | - Thiago C Amorim
- Neuroengineering Program, Edmond and Lily Safra International Neuroscience Institute, Santos Dumont Institute, Rodovia RN 160, Km 03, 3001 Distrito Jundiaí, Macaíba, 59280-000, Brazil
| | - Matheus O Lacerda
- Federal University of Rio Grande do Norte, Av. Sen. Salgado Filho Lagoa Nova, Natal, 59078-970, Brazil
| | - Camila R Simão
- Federal University of Rio Grande do Norte, Av. Sen. Salgado Filho Lagoa Nova, Natal, 59078-970, Brazil.,Anita Garibaldi Center of Education and Research in Health, Santos Dumont Institute, Rodovia RN 160, Km 02, 2010 Distrito Jundiaí, Macaíba, 59280-970, Brazil
| | - Edgard Morya
- Neuroengineering Program, Edmond and Lily Safra International Neuroscience Institute, Santos Dumont Institute, Rodovia RN 160, Km 03, 3001 Distrito Jundiaí, Macaíba, 59280-000, Brazil.,Anita Garibaldi Center of Education and Research in Health, Santos Dumont Institute, Rodovia RN 160, Km 02, 2010 Distrito Jundiaí, Macaíba, 59280-970, Brazil
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19
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Leech KA, Kim HE, Hornby TG. Strategies to augment volitional and reflex function may improve locomotor capacity following incomplete spinal cord injury. J Neurophysiol 2017; 119:894-903. [PMID: 29093168 DOI: 10.1152/jn.00051.2017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Many studies highlight the remarkable plasticity demonstrated by spinal circuits following an incomplete spinal cord injury (SCI). Such plasticity can contribute to improvements in volitional motor recovery, such as walking function, although similar mechanisms underlying this recovery may also contribute to the manifestation of exaggerated responses to afferent input, or spastic behaviors. Rehabilitation interventions directed toward augmenting spinal excitability have shown some initial success in improving locomotor function. However, the potential effects of these strategies on involuntary motor behaviors may be of concern. In this article, we provide a brief review of the mechanisms underlying recovery of volitional function and exaggerated reflexes, and the potential overlap between these changes. We then highlight findings from studies that explore changes in spinal excitability during volitional movement in controlled conditions, as well as altered kinematic and behavioral performance during functional tasks. The initial focus will be directed toward recovery of reflex and volitional behaviors following incomplete SCI, followed by recent work elucidating neurophysiological mechanisms underlying patterns of static and dynamic muscle activation following chronic incomplete SCI during primarily single-joint movements. We will then transition to studies of locomotor function and the role of altered spinal integration following incomplete SCI, including enhanced excitability of specific spinal circuits with physical and pharmacological interventions that can modulate locomotor output. The effects of previous and newly developed strategies will need to focus on changes in both volitional function and involuntary spastic reflexes for the successful translation of effective therapies to the clinical setting.
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Affiliation(s)
- Kristan A Leech
- Department of Neuroscience, Johns Hopkins University , Baltimore, Maryland
| | - Hyosub E Kim
- Department of Psychology, University of California at Berkeley , Berkeley, California
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20
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Smith AC, Knikou M, Yelick KL, Alexander AR, Murnane MM, Kritselis AA, Houmpavlis PJ, McPherson JG, Wasielewski M, Hoggarth MA, Elliott JM. MRI measures of fat infiltration in the lower extremities following motor incomplete spinal cord injury: reliability and potential implications for muscle activation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:5451-5456. [PMID: 28269491 DOI: 10.1109/embc.2016.7591960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Muscle fat infiltration (MFI) is an expected consequence of incomplete spinal cord injury (iSCI). The MFI magnitude may have clinical value in determining functional recovery. However, there is a lack of understanding of how MFI relates to the volitional muscle activity in people with motor incomplete spinal cord injury (iSCI). Five iSCI and 5 uninjured age-matched control subjects participated in the study. In this preliminary study, we established the reliability of MFI quantification of select lower extremity muscles across different raters. Secondly, we assessed the magnitude and distribution of MFI in the lower legs of iSCI and uninjured control participants. Thirdly, we explored the relationship between MFI in the plantar flexor muscles and the ability to volitionally activate these muscles. High levels of inter-rater reliability were observed. The iSCI group had significantly elevated and a vastly different MFI distribution in the lower leg muscles compared to healthy controls. MFI was negatively correlated with volitional activation in iSCI. Our preliminary results sanction the importance of lower extremity MFI quantification as a potential measure in determining the functional outcomes in iSCI, and the subsequent pathological sequelae.
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21
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Nam KY, Kim HJ, Kwon BS, Park JW, Lee HJ, Yoo A. Robot-assisted gait training (Lokomat) improves walking function and activity in people with spinal cord injury: a systematic review. J Neuroeng Rehabil 2017; 14:24. [PMID: 28330471 PMCID: PMC5363005 DOI: 10.1186/s12984-017-0232-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 03/10/2017] [Indexed: 12/29/2022] Open
Abstract
Abstract Robot-assisted gait training (RAGT) after spinal cord injury (SCI) induces several different neurophysiological mechanisms to restore walking ability, including the activation of central pattern generators, task-specific stepping practice and massed exercise. However, there is no clear evidence for the optimal timing and efficacy of RAGT in people with SCI. The aim of our study was to assess the effects of RAGT on improvement in walking-related functional outcomes in patients with incomplete SCI compared with other rehabilitation modalities according to time elapsed since injury. This review included 10 trials involving 502 participants to meta-analysis. The acute RAGT groups showed significantly greater improvements in gait distance, leg strength, and functional level of mobility and independence than the over-ground training (OGT) groups. The pooled mean difference was 45.05 m (95% CI 13.81 to 76.29, P = 0.005, I2 = 0%; two trials, 122 participants), 2.54 (LEMS, 95% CI 0.11 to 4.96, P = 0.04, I2 = 0%; three trials, 211 participants) and 0.5 (WISCI-II and FIM-L, 95% CI 0.02 to 0.98, P = 0.04, I2 = 67%; three trials, 211 participants), respectively. In the chronic RAGT group, significantly greater improvements in speed (pooled mean difference = 0.07 m/s, 95% CI 0.01 to 0.12, P = 0.01, I2 = 0%; three trials, 124 participants) and balance measured by TUG (pooled mean difference = 9.25, 95% CI 2.76 to 15.73, P = 0.005, I2 = 74%; three trials, 120 participants) were observed than in the group with no intervention. Thus, RAGT improves mobility-related outcomes to a greater degree than conventional OGT for patients with incomplete SCI, particularly during the acute stage. RAGT treatment is a promising technique to restore functional walking and improve locomotor ability, which might enable SCI patients to maintain a healthy lifestyle and increase their level of physical activity. Trial registration PROSPERO (CRD 42016037366). Registered 6 April 2016.
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Affiliation(s)
- Ki Yeun Nam
- Department of Physical Medicine & Rehabilitation, Dongguk University College of Medicine, Goyang, Korea
| | - Hyun Jung Kim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, Korea
| | - Bum Sun Kwon
- Department of Physical Medicine & Rehabilitation, Dongguk University College of Medicine, Goyang, Korea
| | - Jin-Woo Park
- Department of Physical Medicine & Rehabilitation, Dongguk University College of Medicine, Goyang, Korea
| | - Ho Jun Lee
- Department of Physical Medicine & Rehabilitation, Dongguk University College of Medicine, Goyang, Korea
| | - Aeri Yoo
- Central Seoul Eye Center, Seoul, South Korea.
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22
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Field-Fote EC, Yang JF, Basso DM, Gorassini MA. Supraspinal Control Predicts Locomotor Function and Forecasts Responsiveness to Training after Spinal Cord Injury. J Neurotrauma 2016; 34:1813-1825. [PMID: 27673569 DOI: 10.1089/neu.2016.4565] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Restoration of walking ability is an area of great interest in the rehabilitation of persons with spinal cord injury. Because many cortical, subcortical, and spinal neural centers contribute to locomotor function, it is important that intervention strategies be designed to target neural elements at all levels of the neuraxis that are important for walking ability. While to date most strategies have focused on activation of spinal circuits, more recent studies are investigating the value of engaging supraspinal circuits. Despite the apparent potential of pharmacological, biological, and genetic approaches, as yet none has proved more effective than physical therapeutic rehabilitation strategies. By making optimal use of the potential of the nervous system to respond to training, strategies can be developed that meet the unique needs of each person. To complement the development of optimal training interventions, it is valuable to have the ability to predict future walking function based on early clinical presentation, and to forecast responsiveness to training. A number of clinical prediction rules and association models based on common clinical measures have been developed with the intent, respectively, to predict future walking function based on early clinical presentation, and to delineate characteristics associated with responsiveness to training. Further, a number of variables that are correlated with walking function have been identified. Not surprisingly, most of these prediction rules, association models, and correlated variables incorporate measures of volitional lower extremity strength, illustrating the important influence of supraspinal centers in the production of walking behavior in humans.
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Affiliation(s)
- Edelle C Field-Fote
- 1 Shepherd Center, Crawford Research Institute and Division of Physical Therapy, Emory University , Atlanta, Georgia
| | - Jaynie F Yang
- 2 Department of Physical Therapy, Faculty of Rehabilitation Medicine and Neuroscience and Mental Health Institute, Faculty of Medicine & Dentistry, University of Alberta , Edmonton, Alberta, Canada
| | - D Michele Basso
- 3 School of Health and Rehabilitation Sciences, The Ohio State University , Columbus, Ohio
| | - Monica A Gorassini
- 4 Department of Biomedical Engineering, Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta, Canada
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23
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Mercier C, Roosink M, Bouffard J, Bouyer LJ. Promoting Gait Recovery and Limiting Neuropathic Pain After Spinal Cord Injury. Neurorehabil Neural Repair 2016; 31:315-322. [PMID: 27913797 PMCID: PMC5405804 DOI: 10.1177/1545968316680491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Most persons living with a spinal cord injury experience neuropathic pain in the months following their lesion, at the moment where they receive intensive gait rehabilitation. Based on studies using animal models, it has been proposed that central sensitization in nociceptive pathways (maladaptive plasticity) and plasticity related to motor learning (adaptive plasticity) share common neural mechanisms and compete with each other. This article aims to address the discrepancy between the growing body of basic science literature supporting this hypothesis and the general belief in rehabilitation research that pain and gait rehabilitation represent two independent problems. First, the main findings from basic research showing interactions between nociception and learning in the spinal cord will be summarized, focusing both on evidence demonstrating the impact of nociception on motor learning and of motor learning on central sensitization. Then, the generalizability of these findings in animal models to humans will be discussed. Finally, the way potential interactions between nociception and motor learning are currently taken into account in clinical research in patients with spinal cord injury will be presented. To conclude, recommendations will be proposed to better integrate findings from basic research into future clinical research in persons with spinal cord injury.
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Affiliation(s)
- Catherine Mercier
- 1 Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Quebec City, Quebec, Canada.,2 Laval University, Quebec City, Quebec, Canada
| | - Meyke Roosink
- 1 Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Quebec City, Quebec, Canada
| | - Jason Bouffard
- 1 Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Quebec City, Quebec, Canada.,2 Laval University, Quebec City, Quebec, Canada
| | - Laurent J Bouyer
- 1 Centre Interdisciplinaire de Recherche en Réadaptation et Intégration Sociale, Quebec City, Quebec, Canada.,2 Laval University, Quebec City, Quebec, Canada
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24
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Côté MP, Murray M, Lemay MA. Rehabilitation Strategies after Spinal Cord Injury: Inquiry into the Mechanisms of Success and Failure. J Neurotrauma 2016; 34:1841-1857. [PMID: 27762657 DOI: 10.1089/neu.2016.4577] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Body-weight supported locomotor training (BWST) promotes recovery of load-bearing stepping in lower mammals, but its efficacy in individuals with a spinal cord injury (SCI) is limited and highly dependent on injury severity. While animal models with complete spinal transections recover stepping with step-training, motor complete SCI individuals do not, despite similarly intensive training. In this review, we examine the significant differences between humans and animal models that may explain this discrepancy in the results obtained with BWST. We also summarize the known effects of SCI and locomotor training on the muscular, motoneuronal, interneuronal, and supraspinal systems in human and non-human models of SCI and address the potential causes for failure to translate to the clinic. The evidence points to a deficiency in neuronal activation as the mechanism of failure, rather than muscular insufficiency. While motoneuronal and interneuronal systems cannot be directly probed in humans, the changes brought upon by step-training in SCI animal models suggest a beneficial re-organization of the systems' responsiveness to descending and afferent feedback that support locomotor recovery. The literature on partial lesions in humans and animal models clearly demonstrate a greater dependency on supraspinal input to the lumbar cord in humans than in non-human mammals for locomotion. Recent results with epidural stimulation that activates the lumbar interneuronal networks and/or increases the overall excitability of the locomotor centers suggest that these centers are much more dependent on the supraspinal tonic drive in humans. Sensory feedback shapes the locomotor output in animal models but does not appear to be sufficient to drive it in humans.
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Affiliation(s)
- Marie-Pascale Côté
- 1 Department of Neurobiology and Anatomy, Drexel University College of Medicine , Philadelphia, Pennsylvania
| | - Marion Murray
- 1 Department of Neurobiology and Anatomy, Drexel University College of Medicine , Philadelphia, Pennsylvania
| | - Michel A Lemay
- 2 Department of Bioengineering, Temple University , Philadelphia, Pennsylvania
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Klarner T, Barss TS, Sun Y, Kaupp C, Loadman PM, Zehr EP. Long-Term Plasticity in Reflex Excitability Induced by Five Weeks of Arm and Leg Cycling Training after Stroke. Brain Sci 2016; 6:brainsci6040054. [PMID: 27827888 PMCID: PMC5187568 DOI: 10.3390/brainsci6040054] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/22/2016] [Accepted: 10/28/2016] [Indexed: 12/21/2022] Open
Abstract
Neural connections remain partially viable after stroke, and access to these residual connections provides a substrate for training-induced plasticity. The objective of this project was to test if reflex excitability could be modified with arm and leg (A & L) cycling training. Nineteen individuals with chronic stroke (more than six months postlesion) performed 30 min of A & L cycling training three times a week for five weeks. Changes in reflex excitability were inferred from modulation of cutaneous and stretch reflexes. A multiple baseline (three pretests) within-subject control design was used. Plasticity in reflex excitability was determined as an increase in the conditioning effect of arm cycling on soleus stretch reflex amplitude on the more affected side, by the index of modulation, and by the modulation ratio between sides for cutaneous reflexes. In general, A & L cycling training induces plasticity and modifies reflex excitability after stroke.
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Affiliation(s)
- Taryn Klarner
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
- Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, BC V5Z 1M9, Canada.
- Centre for Biomedical Research, University of Victoria, Victoria, BC V8W 2Y2, Canada.
| | - Trevor S Barss
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
- Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, BC V5Z 1M9, Canada.
- Centre for Biomedical Research, University of Victoria, Victoria, BC V8W 2Y2, Canada.
| | - Yao Sun
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
- Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, BC V5Z 1M9, Canada.
- Centre for Biomedical Research, University of Victoria, Victoria, BC V8W 2Y2, Canada.
| | - Chelsea Kaupp
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
- Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, BC V5Z 1M9, Canada.
- Centre for Biomedical Research, University of Victoria, Victoria, BC V8W 2Y2, Canada.
| | - Pamela M Loadman
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
| | - E Paul Zehr
- Rehabilitation Neuroscience Laboratory, University of Victoria, Victoria, BC V8W 3P1, Canada.
- Human Discovery Science, International Collaboration on Repair Discoveries (ICORD), Vancouver, BC V5Z 1M9, Canada.
- Centre for Biomedical Research, University of Victoria, Victoria, BC V8W 2Y2, Canada.
- Division of Medical Sciences, University of Victoria, BC V8P 5C2, Canada.
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Training-Specific Neural Plasticity in Spinal Reflexes after Incomplete Spinal Cord Injury. Neural Plast 2016; 2016:6718763. [PMID: 27725887 PMCID: PMC5048024 DOI: 10.1155/2016/6718763] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 07/27/2016] [Accepted: 08/03/2016] [Indexed: 11/17/2022] Open
Abstract
The neural plasticity of spinal reflexes after two contrasting forms of walking training was determined in individuals with chronic, motor-incomplete spinal cord injury (SCI). Endurance Training involved treadmill walking for as long as possible, and Precision Training involved walking precisely over obstacles and onto targets overground. Twenty participants started either Endurance or Precision Training for 2 months and then crossed over after a 2-month rest period to the other form of training for 2 months. Measures were taken before and after each phase of training and rest. The cutaneomuscular reflex (CMR) during walking was evoked in the soleus (SOL) and tibialis anterior muscles by stimulating the posterior tibial nerve at the ankle. Clonus was estimated from the EMG power in the SOL during unperturbed walking. The inhibitory component of the SOL CMR was enhanced after Endurance but not Precision Training. Clonus did not change after either form of training. Participants with lower reflex excitability tended to be better walkers (i.e., faster walking speeds) prior to training, and the reduction in clonus was significantly correlated with the improvement in walking speed and distance. Thus, reflex excitability responded in a training-specific way, with the reduction in reflex excitability related to improvements in walking function. Trial registration number is NCT01765153.
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Smith AC, Knikou M. A Review on Locomotor Training after Spinal Cord Injury: Reorganization of Spinal Neuronal Circuits and Recovery of Motor Function. Neural Plast 2016; 2016:1216258. [PMID: 27293901 PMCID: PMC4879237 DOI: 10.1155/2016/1216258] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 04/20/2016] [Indexed: 01/01/2023] Open
Abstract
Locomotor training is a classic rehabilitation approach utilized with the aim of improving sensorimotor function and walking ability in people with spinal cord injury (SCI). Recent studies have provided strong evidence that locomotor training of persons with clinically complete, motor complete, or motor incomplete SCI induces functional reorganization of spinal neuronal networks at multisegmental levels at rest and during assisted stepping. This neuronal reorganization coincides with improvements in motor function and decreased muscle cocontractions. In this review, we will discuss the manner in which spinal neuronal circuits are impaired and the evidence surrounding plasticity of neuronal activity after locomotor training in people with SCI. We conclude that we need to better understand the physiological changes underlying locomotor training, use physiological signals to probe recovery over the course of training, and utilize established and contemporary interventions simultaneously in larger scale research studies. Furthermore, the focus of our research questions needs to change from feasibility and efficacy to the following: what are the physiological mechanisms that make it work and for whom? The aforementioned will enable the scientific and clinical community to develop more effective rehabilitation protocols maximizing sensorimotor function recovery in people with SCI.
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Affiliation(s)
- Andrew C. Smith
- Interdepartmental Neuroscience Program, Northwestern University, Chicago, IL 60611, USA
| | - Maria Knikou
- The Graduate Center, City University of New York, New York, NY 10016, USA
- Department of Physical Therapy, College of Staten Island, City University of New York, Staten Island, NY 10314, USA
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Minassian K, Hofstoetter US. Spinal Cord Stimulation and Augmentative Control Strategies for Leg Movement after Spinal Paralysis in Humans. CNS Neurosci Ther 2016; 22:262-70. [PMID: 26890324 DOI: 10.1111/cns.12530] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 01/28/2016] [Accepted: 01/28/2016] [Indexed: 12/30/2022] Open
Abstract
Severe spinal cord injury is a devastating condition, tearing apart long white matter tracts and causing paralysis and disability of body functions below the lesion. But caudal to most injuries, the majority of neurons forming the distributed propriospinal system, the localized gray matter spinal interneuronal circuitry, and spinal motoneuron populations are spared. Epidural spinal cord stimulation can gain access to this neural circuitry. This review focuses on the capability of the human lumbar spinal cord to generate stereotyped motor output underlying standing and stepping, as well as full weight-bearing standing and rhythmic muscle activation during assisted treadmill stepping in paralyzed individuals in response to spinal cord stimulation. By enhancing the excitability state of the spinal circuitry, the stimulation can have an enabling effect upon otherwise "silent" translesional volitional motor control. Strategies for achieving functional movement in patients with severe injuries based on minimal translesional intentional control, task-specific proprioceptive feedback, and next-generation spinal cord stimulation systems will be reviewed. The role of spinal cord stimulation can go well beyond the immediate generation of motor output. With recently developed training paradigms, it can become a major rehabilitation approach in spinal cord injury for augmenting and steering trans- and sublesional plasticity for lasting therapeutic benefits.
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Affiliation(s)
- Karen Minassian
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
| | - Ursula S Hofstoetter
- Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria
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Stutzig N, Siebert T. Assessment of the H-reflex at two contraction levels before and after fatigue. Scand J Med Sci Sports 2016; 27:399-407. [PMID: 26887575 DOI: 10.1111/sms.12663] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2016] [Indexed: 12/28/2022]
Abstract
The aim of the present study was to compare the H-reflex evoked at rest and at 20% maximal voluntary contraction (MVC) prior to and after fatiguing the lateral gastrocnemius (LG). The maximal H-reflex and M-wave were recorded in the LG, and soleus (SOL). Electrical evoked potentials were delivered to the posterior tibial nerve when muscles were inactivated and at 20% MVC. After fatigue, the Hmax /Mmax ratio of the fatigued LG was increased for both contraction levels (rest and 20% MVC) and remained unaltered for non-fatigued SOL. Before fatigue, the Hmax /Mmax ratio of SOL was enhanced at rest compared with the Hmax /Mmax ratio at 20% MVC. No differences were observed for LG. Fatigue of a single muscle leads to increased spinal reflex activity of the homonymous muscle. Contrary to previous recommendations in the literature, there appears to be no benefit with regard to the H-reflex amplitude in evoking electrical potentials during constant voluntary contractions at 20% MVC compared with inactivated muscles. The observed difference in SOL prior to fatigue was most likely due to hyperpolarization of the muscle fiber membrane.
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Affiliation(s)
- N Stutzig
- Department of Exercise Science, Institute of Sport- and Movement Science, University of Stuttgart, Stuttgart, Germany
| | - T Siebert
- Department of Exercise Science, Institute of Sport- and Movement Science, University of Stuttgart, Stuttgart, Germany
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Stevenson AJ, Mrachacz-Kersting N, van Asseldonk E, Turner DL, Spaich EG. Spinal plasticity in robot-mediated therapy for the lower limbs. J Neuroeng Rehabil 2015; 12:81. [PMID: 26377324 PMCID: PMC4574007 DOI: 10.1186/s12984-015-0073-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/03/2015] [Indexed: 12/02/2022] Open
Abstract
Robot-mediated therapy can help improve walking ability in patients following injuries to the central nervous system. However, the efficacy of this treatment varies between patients, and evidence for the mechanisms underlying functional improvements in humans is poor, particularly in terms of neural changes in the spinal cord. Here, we review the recent literature on spinal plasticity induced by robotic-based training in humans and propose recommendations for the measurement of spinal plasticity using robotic devices. Evidence for spinal plasticity in humans following robotic training is limited to the lower limbs. Body weight-supported (BWS) robotic-assisted step training of patients with spinal cord injury (SCI) or stroke patients has been shown to lead to changes in the amplitude and phase modulation of spinal reflex pathways elicited by electrical stimulation or joint rotations. Of particular importance is the finding that, among other changes to the spinal reflex circuitries, BWS robotic-assisted step training in SCI patients resulted in the re-emergence of a physiological phase modulation of the soleus H-reflex during walking. Stretch reflexes elicited by joint rotations constitute a tool of interest to probe spinal circuitry since the technology necessary to produce these perturbations could be integrated as a natural part of robotic devices. Presently, ad-hoc devices with an actuator capable of producing perturbations powerful enough to elicit the reflex are available but are not part of robotic devices used for training purposes. A further development of robotic devices that include the technology to elicit stretch reflexes would allow for the spinal circuitry to be routinely tested as a part of the training and evaluation protocols.
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Affiliation(s)
- Andrew Jt Stevenson
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D-3, Aalborg, DK 9220, Denmark.
| | - Natalie Mrachacz-Kersting
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D-3, Aalborg, DK 9220, Denmark.
| | - Edwin van Asseldonk
- Biomedical Engineering, University of Twente, 7522NB, Enschede, The Netherlands.
| | - Duncan L Turner
- NeuroRehabilitation Unit, School of Health, Sport and Bioscience, University of East London, London, E15 4LZ, England.
| | - Erika G Spaich
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7 D-3, Aalborg, DK 9220, Denmark.
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31
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Strategies and lessons in spinal cord injury rehabilitation. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2015. [DOI: 10.1007/s40141-015-0096-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kumru H, Albu S, Valls-Sole J, Murillo N, Tormos JM, Vidal J. Influence of spinal cord lesion level and severity on H-reflex excitability and recovery curve. Muscle Nerve 2015; 52:616-22. [DOI: 10.1002/mus.24579] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 01/02/2015] [Accepted: 01/12/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Hatice Kumru
- Institut Guttmann; Institut Universitari de Neurorehabilitació adscrit a la UAB; 08916 Badalona and Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona Barcelona Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès); Spain
- Fundació Institut d‘Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona, Barcelona Spain
| | - Sergiu Albu
- Texas A&M University; College Station, Texas 77843-4235 USA
| | | | - Narda Murillo
- Institut Guttmann; Institut Universitari de Neurorehabilitació adscrit a la UAB; 08916 Badalona and Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona Barcelona Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès); Spain
- Fundació Institut d‘Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona, Barcelona Spain
| | - Josep Maria Tormos
- Institut Guttmann; Institut Universitari de Neurorehabilitació adscrit a la UAB; 08916 Badalona and Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona Barcelona Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès); Spain
- Fundació Institut d‘Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona, Barcelona Spain
| | - Joan Vidal
- Institut Guttmann; Institut Universitari de Neurorehabilitació adscrit a la UAB; 08916 Badalona and Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona Barcelona Spain
- Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès); Spain
- Fundació Institut d‘Investigació en Ciències de la Salut Germans Trias i Pujol; Badalona, Barcelona Spain
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Knikou M, Smith AC, Mummidisetty CK. Locomotor training improves reciprocal and nonreciprocal inhibitory control of soleus motoneurons in human spinal cord injury. J Neurophysiol 2015; 113:2447-60. [PMID: 25609110 DOI: 10.1152/jn.00872.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/20/2015] [Indexed: 12/19/2022] Open
Abstract
Pathologic reorganization of spinal networks and activity-dependent plasticity are common neuronal adaptations after spinal cord injury (SCI) in humans. In this work, we examined changes of reciprocal Ia and nonreciprocal Ib inhibition after locomotor training in 16 people with chronic SCI. The soleus H-reflex depression following common peroneal nerve (CPN) and medial gastrocnemius (MG) nerve stimulation at short conditioning-test (C-T) intervals was assessed before and after training in the seated position and during stepping. The conditioned H reflexes were normalized to the unconditioned H reflex recorded during seated. During stepping, both H reflexes were normalized to the maximal M wave evoked at each bin of the step cycle. In the seated position, locomotor training replaced reciprocal facilitation with reciprocal inhibition in all subjects, and Ib facilitation was replaced by Ib inhibition in 13 out of 14 subjects. During stepping, reciprocal inhibition was decreased at early stance and increased at midswing in American Spinal Injury Association Impairment Scale C (AIS C) and was decreased at midstance and midswing phases in AIS D after training. Ib inhibition was decreased at early swing and increased at late swing in AIS C and was decreased at early stance phase in AIS D after training. The results of this study support that locomotor training alters postsynaptic actions of Ia and Ib inhibitory interneurons on soleus motoneurons at rest and during stepping and that such changes occur in cases with limited or absent supraspinal inputs.
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Affiliation(s)
- Maria Knikou
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, Illinois; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg Medical School, Chicago, Illinois; Graduate Center/The City University of New York, New York, New York; and Department of Physical Therapy, College of Staten Island, Staten Island, New York
| | - Andrew C Smith
- Northwestern University Interdepartmental Neuroscience Program, Chicago, Illinois
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Facilitation of descending excitatory and spinal inhibitory networks from training of endurance and precision walking in participants with incomplete spinal cord injury. PROGRESS IN BRAIN RESEARCH 2015; 218:127-55. [DOI: 10.1016/bs.pbr.2014.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Smith AC, Rymer WZ, Knikou M. Locomotor training modifies soleus monosynaptic motoneuron responses in human spinal cord injury. Exp Brain Res 2014; 233:89-103. [PMID: 25205562 DOI: 10.1007/s00221-014-4094-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 08/29/2014] [Indexed: 01/15/2023]
Abstract
The objective of this study was to assess changes in monosynaptic motoneuron responses to stimulation of Ia afferents after locomotor training in individuals with chronic spinal cord injury (SCI). We hypothesized that locomotor training modifies the amplitude of the soleus monosynaptic motoneuron responses in a body position-dependent manner. Fifteen individuals with chronic clinical motor complete or incomplete SCI received an average of 45 locomotor training sessions. The soleus H-reflex and M-wave recruitment curves were assembled using data collected in both the right and left legs, with subjects seated and standing, before and after training. The soleus H-reflexes and M-waves, measured as peak-to-peak amplitudes, were normalized to the maximal M-wave (M(max)). Stimulation intensities were normalized to 50% M(max) stimulus intensity. A sigmoid function was also fitted to the normalized soleus H-reflexes on the ascending limb of the recruitment curve. After training, soleus H-reflex excitability was increased in both legs in AIS C subjects, and remained unchanged in AIS A-B and AIS D subjects during standing. When subjects were seated, soleus H-reflex excitability was decreased after training in many AIS C and D subjects. Changes in reflex excitability coincided with changes in stimulation intensities at H-threshold, 50% maximal H-reflex, and at maximal H-reflex, while an interaction between leg side and AIS scale for the H-reflex slope was also found. Adaptations of the intrinsic properties of soleus motoneurons and Ia afferents, the excitability profile of the soleus motoneuron pool, oligosynaptic inputs, and corticospinal inputs may all contribute to these changes. The findings of this study demonstrate that locomotor training impacts the amplitude of the monosynaptic motoneuron responses based on the demands of the motor task in people with chronic SCI.
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Affiliation(s)
- Andrew C Smith
- Northwestern University Interdepartmental Neuroscience Program, Chicago, IL, 60611, USA
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Smith AC, Mummidisetty CK, Rymer WZ, Knikou M. Locomotor training alters the behavior of flexor reflexes during walking in human spinal cord injury. J Neurophysiol 2014; 112:2164-75. [PMID: 25122715 DOI: 10.1152/jn.00308.2014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In humans, a chronic spinal cord injury (SCI) impairs the excitability of pathways mediating early flexor reflexes and increases the excitability of late, long-lasting flexor reflexes. We hypothesized that in individuals with SCI, locomotor training will alter the behavior of these spinally mediated reflexes. Nine individuals who had either chronic clinically motor complete or incomplete SCI received an average of 44 locomotor training sessions. Flexor reflexes, elicited via sural nerve stimulation of the right or left leg, were recorded from the ipsilateral tibialis anterior (TA) muscle before and after body weight support (BWS)-assisted treadmill training. The modulation pattern of the ipsilateral TA responses following innocuous stimulation of the right foot was also recorded in 10 healthy subjects while they stepped at 25% BWS to investigate whether body unloading during walking affects the behavior of these responses. Healthy subjects did not receive treadmill training. We observed a phase-dependent modulation of early TA flexor reflexes in healthy subjects with reduced body weight during walking. The early TA flexor reflexes were increased at heel contact, progressively decreased during the stance phase, and then increased throughout the swing phase. In individuals with SCI, locomotor training induced the reappearance of early TA flexor reflexes and changed the amplitude of late TA flexor reflexes during walking. Both early and late TA flexor reflexes were modulated in a phase-dependent pattern after training. These new findings support the adaptive capability of the injured nervous system to return to a prelesion excitability and integration state.
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Affiliation(s)
- Andrew C Smith
- Northwestern University Interdepartmental Neuroscience Program, Chicago, Illinios
| | | | - William Zev Rymer
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, Illinois; Northwestern University Interdepartmental Neuroscience Program, Chicago, Illinios; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg Medical School, Chicago, Illinois
| | - Maria Knikou
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, Illinois; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg Medical School, Chicago, Illinois; Graduate Center/The City University of New York, New York, New York; and Department of Physical Therapy, College of Staten Island, Staten Island, New York
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Knikou M, Mummidisetty CK. Locomotor training improves premotoneuronal control after chronic spinal cord injury. J Neurophysiol 2014; 111:2264-75. [PMID: 24598526 DOI: 10.1152/jn.00871.2013] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Spinal inhibition is significantly reduced after spinal cord injury (SCI) in humans. In this work, we examined if locomotor training can improve spinal inhibition exerted at a presynaptic level. Sixteen people with chronic SCI received an average of 45 training sessions, 5 days/wk, 1 h/day. The soleus H-reflex depression in response to low-frequency stimulation, presynaptic inhibition of soleus Ia afferent terminals following stimulation of the common peroneal nerve, and bilateral EMG recovery patterns were assessed before and after locomotor training. The soleus H reflexes evoked at 1.0, 0.33, 0.20, 0.14, and 0.11 Hz were normalized to the H reflex evoked at 0.09 Hz. Conditioned H reflexes were normalized to the associated unconditioned H reflex evoked with subjects seated, while during stepping both H reflexes were normalized to the maximal M wave evoked after the test H reflex at each bin of the step cycle. Locomotor training potentiated homosynaptic depression in all participants regardless the type of the SCI. Presynaptic facilitation of soleus Ia afferents remained unaltered in motor complete SCI patients. In motor incomplete SCIs, locomotor training either reduced presynaptic facilitation or replaced presynaptic facilitation with presynaptic inhibition at rest. During stepping, presynaptic inhibition was modulated in a phase-dependent manner. Locomotor training changed the amplitude of locomotor EMG excitability, promoted intralimb and interlimb coordination, and altered cocontraction between knee and ankle antagonistic muscles differently in the more impaired leg compared with the less impaired leg. The results provide strong evidence that locomotor training improves premotoneuronal control after SCI in humans at rest and during walking.
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Affiliation(s)
- Maria Knikou
- Sensory Motor Performance Program, Rehabilitation Institute of Chicago, Chicago, Illinois; Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg Medical School, Chicago, Illinois; Graduate Center/The City University of New York, New York, New York; and Department of Physical Therapy, College of Staten Island, Staten Island, New York
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38
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Knikou M, Hajela N, Mummidisetty CK. Corticospinal excitability during walking in humans with absent and partial body weight support. Clin Neurophysiol 2013; 124:2431-8. [DOI: 10.1016/j.clinph.2013.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 05/16/2013] [Accepted: 06/06/2013] [Indexed: 12/31/2022]
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