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Frey VN, Langthaler PB, Renz N, Zimmermann G, Höhn C, Schwenker K, Thomschewski A, Kunz AB, Höller Y, Nardone R, Trinka E. Influence of sports on cortical excitability in patients with spinal cord injury: a TMS study. FRONTIERS IN MEDICAL TECHNOLOGY 2024; 6:1297552. [PMID: 38812566 PMCID: PMC11133579 DOI: 10.3389/fmedt.2024.1297552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 04/19/2024] [Indexed: 05/31/2024] Open
Abstract
Background Patients with spinal cord injury (SCI) show abnormal cortical excitability that might be caused by deafferentation. We hypothesize a reduced short-interval intracortical inhibition preceding movement in patients with SCI compared with healthy participants. In addition, we expect that neuroplasticity induced by different types of sports can modulate intracortical inhibition during movement preparation in patients with SCI. Methods We used a reaction test and paired-pulse transcranial magnetic stimulation to record cortical excitability, assessed by measuring amplitudes of motor-evoked potentials in preparation of movement. The participants were grouped as patients with SCI practicing wheelchair dancing (n = 7), other sports (n = 6), no sports (n = 9), and healthy controls (n = 24). Results There were neither significant differences between healthy participants and the patients nor between the different patient groups. A non-significant trend (p = .238), showed that patients engaged in sports have a stronger increase in cortical excitability compared with patients of the non-sportive group, while the patients in the other sports group expressed the highest increase in cortical excitability. Conclusion The small sample sizes limit the statistical power of the study, but the trending effect warrants further investigation of different sports on the neuroplasticity in patients with SCI. It is not clear how neuroplastic changes impact the sensorimotor output of the affected extremities in a patient. This needs to be followed up in further studies with a greater sample size.
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Affiliation(s)
- Vanessa N. Frey
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
| | - Patrick B. Langthaler
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
- Department of Mathematics, Paris Lodron University, Salzburg, Austria
| | - Nora Renz
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
| | - Georg Zimmermann
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- IDA Lab Salzburg, Team Biostatistics and Big Medical Data, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christopher Höhn
- Laboratory for Sleep, Cognition and Consciousness Research, Department of Psychology, Centre for Cognitive Neuroscience, University of Salzburg, Salzburg, Austria
| | - Kerstin Schwenker
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology Salzburg, Salzburg, Austria
| | - Aljoscha Thomschewski
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
| | - Alexander B. Kunz
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology Salzburg, Salzburg, Austria
| | - Yvonne Höller
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Faculty of Psychology, University of Akureyri, Akureyri, Iceland
| | - Raffaele Nardone
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology Salzburg, Salzburg, Austria
- Department of Neurology, Tappeiner Hospital, Meran, Italy
| | - Eugen Trinka
- Department of Neurology, Neurointensive Care and Neurorehabilitation, Member of the European Reference Network EpiCARE, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
- Spinal Cord Injury and Tissue Regeneration Center, Paracelsus Medical University, Salzburg, Austria
- Karl Landsteiner Institute for Neurorehabilitation and Space Neurology Salzburg, Salzburg, Austria
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Calabrò RS, Portaro S, Tomasello P, Porcari B, Balletta T, Naro A. Paving the way for a better management of pain in patients with spinal cord injury: An exploratory study on the use of Functional Electric Stimulation(FES)-cycling. J Spinal Cord Med 2023; 46:107-117. [PMID: 34369852 PMCID: PMC9897777 DOI: 10.1080/10790268.2021.1961050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
CONTEXT/OBJECTIVE Chronic pain is common in patients with spinal cord injury (SCI), for whom it negatively affects quality of life, and its treatment requires an integrated approach. To this end, lower limb functional electrical stimulation (FES) cycling holds promise. OBJECTIVE To investigate pain reduction in a sample of patients with SCI by means of lower limb rehabilitation using FES cycling. DESIGN, SETTING AND PARTICIPANTS Sixteen patients with incomplete and complete SCIs, attending the Neurorobotic Unit of our research institute and reporting pain at or below the level of their SCI were recruited to this exploratory study. INTERVENTIONS Patients undertook two daily sessions of FES cycling, six times weekly, for 6 weeks. OUTCOME MEASURES Pain outcomes were measured using the 0-10 numerical rating scale (NRS), the Multidimensional Pain Inventory for SCI (MPI-SCI), and the 36-Item Short Form Survey (SF-36). Finally, we assessed the features of dorsal laser-evoked potentials (LEPs) to objectively evaluate Aδ fiber pathways. RESULTS All participants tolerated the intervention well, and completed the training without side effects. Statistically significant changes were found in pain-NRS, MPI-SCI, and SF-36 scores, and LEP amplitudes. Following treatment, we found that three patients experienced high pain relief (an NRS decrease of at least 80%), six individuals achieved moderate pain relief (an NRS decrease of about 30-70%), and five participants had mild pain relief (an NRS decrease of less than 30%). CONCLUSION Our preliminary results suggest that FES cycling training is capable of reducing the pain reported by patients with SCI, regardless of American Spinal Injury Association scoring, pain level, or the neurological level of injury. The neurophysiological mechanisms underlying such effects are likely to be both spinal and supraspinal.
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Affiliation(s)
- Rocco Salvatore Calabrò
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy,Correspondence to: Rocco Salvatore Calabrò, IRCCS Centro Neurolesi Bonino Pulejo, via Palermo, SS 113, Ctr. Casazza, Messina98124, Italy; Ph: +3909060128166.
| | | | | | - Bruno Porcari
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Tina Balletta
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
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Maier A, Gaudlitz M, Grehl T, Weyen U, Steinbach R, Grosskreutz J, Rödiger A, Koch JC, Lengenfeld T, Weydt P, Günther R, Wolf J, Baum P, Metelmann M, Dorst J, Ludolph AC, Kettemann D, Norden J, Koc RY, Walter B, Hildebrandt B, Münch C, Meyer T, Spittel S. Use and subjective experience of the impact of motor-assisted movement exercisers in people with amyotrophic lateral sclerosis: a multicenter observational study. Sci Rep 2022; 12:9657. [PMID: 35688956 PMCID: PMC9187150 DOI: 10.1038/s41598-022-13761-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 05/27/2022] [Indexed: 11/16/2022] Open
Abstract
Motor-assisted movement exercisers (MME) are devices that assist with physical therapy in domestic settings for people living with ALS. This observational cross-sectional study assesses the subjective experience of the therapy and analyzes users' likelihood of recommending treatment with MME. The study was implemented in ten ALS centers between February 2019 and October 2020, and was coordinated by the research platform Ambulanzpartner. Participants assessed symptom severity, documented frequency of MME use and rated the subjective benefits of therapy on a numerical scale (NRS, 0 to 10 points, with 10 being the highest). The Net Promotor Score (NPS) determined the likelihood of a participant recommending MME. Data for 144 participants were analyzed. Weekly MME use ranged from 1 to 4 times for 41% of participants, 5 to 7 times for 42%, and over 7 times for 17%. Particularly positive results were recorded in the following domains: amplification of a sense of achievement (67%), diminution of the feeling of having rigid limbs (63%), diminution of the feeling of being immobile (61%), improvement of general wellbeing (55%) and reduction of muscle stiffness (52%). Participants with more pronounced self-reported muscle weakness were more likely to note a beneficial effect on the preservation and improvement of muscle strength during MME treatment (p < 0.05). Overall, the NPS for MME was high (+ 61). High-frequency MME-assisted treatment (defined as a minimum of five sessions a week) was administered in the majority of participants (59%) in addition to physical therapy. Most patients reported having achieved their individual therapeutic objectives, as evidenced by a high level of satisfaction with MME therapy. The results bolster the justification for extended MME treatment as part of a holistic approach to ALS care.
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Affiliation(s)
- André Maier
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.
| | | | - Torsten Grehl
- Department of Neurology, Alfried Krupp Krankenhaus, Center for ALS and Other Motor Neuron Disorders, Essen, Germany
| | - Ute Weyen
- Center for ALS and Other Motor Neuron Disorders, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Germany
| | - Robert Steinbach
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | | | - Annekathrin Rödiger
- Hans Berger Department of Neurology, Jena University Hospital, Jena, Germany
| | - Jan Christoph Koch
- Department of Neurology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Teresa Lengenfeld
- Department of Neurology, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Patrick Weydt
- Universitätsklinikum Bonn-Klinik Für Neurodegenerative Erkrankungen, Bonn, Germany
| | - René Günther
- Department of Neurology, Technische Universität Dresden, Dresden, Deutschland.,Research Site Dresden, German Centre for Neurodegenerative Diseases (DZNE), Dresden, Germany
| | - Joachim Wolf
- Department of Neurology, Diakonissenkrankenhaus Mannheim, Mannheim, Germany
| | - Petra Baum
- Department of Neurology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Moritz Metelmann
- Department of Neurology, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Johannes Dorst
- Department of Neurology, University of Ulm, Ulm, Germany.,German Center for Neurodegenerative Diseases (DZNE), Research Site Ulm, Ulm, Germany
| | - Albert C Ludolph
- Department of Neurology, University of Ulm, Ulm, Germany.,German Center for Neurodegenerative Diseases (DZNE), Research Site Ulm, Ulm, Germany
| | - Dagmar Kettemann
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jenny Norden
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Ruhan Yasemin Koc
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Bertram Walter
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany
| | | | - Christoph Münch
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Thomas Meyer
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
| | - Susanne Spittel
- Outpatient Center for ALS and Other Motor Neuron Diseases, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Augustenburger Platz 1, 13353, Berlin, Germany.,Ambulanzpartner Soziotechnologie APST GmbH, Berlin, Germany
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Sadik ME, Ozturk AK, Albayar A, Branche M, Sullivan PZ, Schlosser LO, Browne KD, Jaye AH, Smith DH. A Strategy Toward Bridging a Complete Spinal Cord Lesion Using Stretch-Grown Axons. Tissue Eng Part A 2020; 26:623-635. [DOI: 10.1089/ten.tea.2019.0230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Mindy Ezra Sadik
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali K. Ozturk
- Department of Neurosurgery, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Ahmed Albayar
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc Branche
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patricia Zadnik Sullivan
- Department of Neurosurgery, Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, Pennsylvania
| | - Laura O. Schlosser
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin D. Browne
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew H. Jaye
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas H. Smith
- Center for Brain Injury and Repair, University of Pennsylvania, Philadelphia, Pennsylvania
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Phadke CP, Vierira L, Mathur S, Cipriano G, Ismail F, Boulias C. Impact of Passive Leg Cycling in Persons With Spinal Cord Injury: A Systematic Review. Top Spinal Cord Inj Rehabil 2018; 25:83-96. [PMID: 30774292 DOI: 10.1310/sci18-00020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background: Passive leg cycling is an important clinical tool available for rehabilitation after spinal cord injury (SCI). Passive cycling can be used to derive exercise-related benefits in patients with poor motor control. There have been a number of studies examining the effects of passive cycling on a variety of outcomes. There is need for a systematic assessment of the cycling parameters and the associated clinical changes in cardiovascular, neuromuscular, and musculoskeletal outcomes after passive cycling. Objectives: To assess the effectiveness of passive leg cycling interventions on cardiovascular, neuromuscular, and musculoskeletal outcomes post SCI, and to describe intensity, duration, and type of passive leg cycling post SCI. Methods: PRISMA guided systematic review of literature based on searches in the following databases: PubMed/MEDLINE, PEDro, EMBASE, Cochrane Library, and Google Scholar. Peer-reviewed publications that were written in English were included if they described the effects of a single session or multiple sessions of passive leg cycling in persons post SCI. Results: Eleven papers were included: two were randomized controlled trials (RCTs), one was a crossover trial, and the rest were pre-post single-group designs. Three studies (including two RCTs) reported statistically significant benefits of multiple sessions of passive cycling on leg blood flow velocity, spasticity, reflex excitability and joint range of motion, and markers of muscle hypertrophy. About half of the single session studies showed statistically significant improvement in acute responses. Conclusion: Multiple sessions of passive leg cycling showed benefits in three categories - cardiovascular, musculoskeletal, and neurological - with medium to large effect sizes.
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Affiliation(s)
- Chetan P Phadke
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Faculty of Health, York University, Toronto, Ontario, Canada.,Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Luciana Vierira
- Health Sciences and Technologies PhD Program, University of Brasilia, Brasilia, Brazil
| | - Sunita Mathur
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Gerson Cipriano
- Division of Physical Therapy - Ceilandia College, University of Brasilia, Brasilia, Brazil
| | - Farooq Ismail
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Division of Physiatry, University of Toronto, Toronto, Ontario, Canada
| | - Chris Boulias
- Spasticity Research Program, West Park Healthcare Centre, Toronto, Ontario, Canada.,Division of Physiatry, University of Toronto, Toronto, Ontario, Canada
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Tørhaug T, Brurok B, Hoff J, Helgerud J, Leivseth G. Arm Cycling Combined with Passive Leg Cycling Enhances VO 2peak in Persons with Spinal Cord Injury Above the Sixth Thoracic Vertebra. Top Spinal Cord Inj Rehabil 2017; 24:86-95. [PMID: 29434464 PMCID: PMC5791928 DOI: 10.1310/sci17-00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Objective: To test whether passive leg cycling (PLC) during arm cycling ergometry (ACE) affects peak oxygen uptake (VO2peak) differently in individuals with spinal cord injury (SCI) at/above the 6th thoracic vertebra (T6) and below T6. Methods: We conducted a cross-sectional study, analyzed by univariate and multivariate regression models. Between- and within-group differences were examined during (a) ACE only, (b) ACE combined with PLC (ACE-PLC), and (c) ACE combined with functional electrical stimulation cycling (FES hybrid). Fifteen SCI subjects were recruited and grouped according to injury level: at/above T6 (SCI-high, n = 8) or below T6 (SCI-low, n = 7). VO2peak tests during ACE only, ACE-PLC, and FES hybrid were performed in random order on separate days. Results: In the SCI-high group, mean (SD) VO2peak was 19% higher during ACE-PLC than during ACE only [21.0 (3.8) vs 17.7 (5.0) mL·kg-1·min-1; p = .002], while VO2peak during FES hybrid cycling was 16% higher than during ACE-PLC [24.4 (4.1) mL·kg-1·min-1; p = .001]. No significant differences among exercise modalities were found for the SCI-low group. Conclusion: Additional training modalities (eg, PLC) during ACE facilitate exercise in SCI-high individuals, but not to the level of the FES hybrid method. Conversely, additional training modalities may not increase training load in SCI-low individuals.
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Affiliation(s)
- Tom Tørhaug
- St. Olavs University Hospital, Clinic of Physical Medicine and Rehabilitation, Department of Spinal Cord Injuries, Trondheim, Norway
- Norwegian University of Science and Technology, Faculty of Medicine, Department of Neuromedicine and Movement Science, Trondheim, Norway
| | - Berit Brurok
- St. Olavs University Hospital, Clinic of Physical Medicine and Rehabilitation, Department of Spinal Cord Injuries, Trondheim, Norway
- K.G. Jebsen Center of Exercise in Medicine, Department of Circulation and Medical Imaging Norwegian University of Science and Technology, Trondheim, Norway
| | - Jan Hoff
- St. Olavs University Hospital, Clinic of Physical Medicine and Rehabilitation, Department of Spinal Cord Injuries, Trondheim, Norway
- Norwegian University of Science and Technology, Faculty of Medicine, Department of Circulation and Imaging, Trondheim, Norway
| | - Jan Helgerud
- Norwegian University of Science and Technology, Faculty of Medicine, Department of Circulation and Imaging, Trondheim, Norway
- Hokksund Medical Rehabilitation Centre, Hokksund, Norway
- Telemark University College, Department of Sports and Outdoor Life Studies, Bø, Norway
| | - Gunnar Leivseth
- Norwegian University of Science and Technology, Faculty of Medicine, Department of Neuromedicine and Movement Science, Trondheim, Norway
- Department of Clinical Medicine, Neuromuscular Diseases Research Group, University of Tromsø, Norway
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