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Guha L, Kumar H. Drug Repurposing for Spinal Cord Injury: Progress Towards Therapeutic Intervention for Primary Factors and Secondary Complications. Pharmaceut Med 2023; 37:463-490. [PMID: 37698762 DOI: 10.1007/s40290-023-00499-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 09/13/2023]
Abstract
Spinal cord injury (SCI) encompasses a plethora of complex mechanisms like the involvement of major cell death pathways, neurodegeneration of spinal cord neurons, overexpression of glutaminergic transmission and inflammation cascade, along with different co-morbidities like neuropathic pain, urinary and sexual dysfunction, respiratory and cardiac failures, making it one of the leading causes of morbidity and mortality globally. Corticosteroids such as methylprednisolone and dexamethasone, and non-steroidal anti-inflammatory drugs such as naproxen, aspirin and ibuprofen are the first-line treatment options for SCI, inhibiting primary and secondary progression by preventing inflammation and action of reactive oxygen species. However, they are constrained by a short effective drug administration window and their pharmacological action being limited to symptomatic relief of the secondary effects related to spinal cord injury only. Although post-injury rehabilitation treatments may enable functional recovery, they take a long time to show results. Drug repurposing might be an innovative method for expanding therapy alternatives, utilising drugs that are already approved by various esteemed federal agencies throughout the world. Reutilising a drug molecule to treat SCI can eliminate the need for expensive and lengthy drug discovery processes and pave the way for new therapeutic approaches in SCI. This review summarises marketed drugs that could be repurposed based on their safety and efficacy data. We also discuss their mechanisms of action and provide a list of repurposed drugs under clinical trials for SCI therapy.
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Affiliation(s)
- Lahanya Guha
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Opposite Air Force Station, Palaj, P.O-382355, Gandhinagar, Gujarat, India
| | - Hemant Kumar
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER)-Ahmedabad, Opposite Air Force Station, Palaj, P.O-382355, Gandhinagar, Gujarat, India.
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Huber E, Patel R, Hupp M, Weiskopf N, Chakravarty MM, Freund P. Extrapyramidal plasticity predicts recovery after spinal cord injury. Sci Rep 2020; 10:14102. [PMID: 32839540 PMCID: PMC7445170 DOI: 10.1038/s41598-020-70805-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 08/05/2020] [Indexed: 11/09/2022] Open
Abstract
Spinal cord injury (SCI) leads to wide-spread neurodegeneration across the neuroaxis. We explored trajectories of surface morphology, demyelination and iron concentration within the basal ganglia-thalamic circuit over 2 years post-SCI. This allowed us to explore the predictive value of neuroimaging biomarkers and determine their suitability as surrogate markers for interventional trials. Changes in markers of surface morphology, myelin and iron concentration of the basal ganglia and thalamus were estimated from 182 MRI datasets acquired in 17 SCI patients and 21 healthy controls at baseline (1-month post injury for patients), after 3, 6, 12, and 24 months. Using regression models, we investigated group difference in linear and non-linear trajectories of these markers. Baseline quantitative MRI parameters were used to predict 24-month clinical outcome. Surface area contracted in the motor (i.e. lower extremity) and pulvinar thalamus, and striatum; and expanded in the motor thalamus and striatum in patients compared to controls over 2-years. In parallel, myelin-sensitive markers decreased in the thalamus, striatum, and globus pallidus, while iron-sensitive markers decreased within the left caudate. Baseline surface area expansions within the striatum (i.e. motor caudate) predicted better lower extremity motor score at 2-years. Extensive extrapyramidal neurodegenerative and reorganizational changes across the basal ganglia-thalamic circuitry occur early after SCI and progress over time; their magnitude being predictive of functional recovery. These results demonstrate a potential role of extrapyramidal plasticity during functional recovery after SCI.
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Affiliation(s)
- E Huber
- Spinal Cord Injury Center Balgrist, University Hospital Zurich, Zurich, Switzerland
| | - R Patel
- Computational Brain Anatomy Laboratory (CoBrA Lab), Douglas Research Centre, Montreal, QC, Canada.,Department of Biological and Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - M Hupp
- Spinal Cord Injury Center Balgrist, University Hospital Zurich, Zurich, Switzerland
| | - N Weiskopf
- Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Felix Bloch Institute for Solid State Physics, Faculty of Physics and Earth Sciences, Leipzig University, Linnéstraße 5, 04103, Leipzig, Germany
| | - M M Chakravarty
- Computational Brain Anatomy Laboratory (CoBrA Lab), Douglas Research Centre, Montreal, QC, Canada.,Department of Biological and Biomedical Engineering, McGill University, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - P Freund
- Spinal Cord Injury Center Balgrist, University Hospital Zurich, Zurich, Switzerland. .,Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, University College London, London, UK. .,Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, UK. .,Department of Neurophysics, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.
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Bradley CL, Damiano DL. Effects of Dopamine on Motor Recovery and Training in Adults and Children With Nonprogressive Neurological Injuries: A Systematic Review. Neurorehabil Neural Repair 2019; 33:331-344. [PMID: 30913975 DOI: 10.1177/1545968319837289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The strong link between dopamine and motor learning has been well-established in the animal literature with similar findings reported in healthy adults and the elderly. OBJECTIVE We aimed to conduct the first, to our knowledge, systematic review of the literature on the evidence for the effects of dopaminergic medications or genetic variations in dopamine transmission on motor recovery or learning after a nonprogressive neurological injury. METHODS A PubMed search was conducted up until April 2018 for all English articles including participants with nonprogressive neurological injury such as cerebral palsy, stroke, spinal cord injury, and traumatic brain injury; quantitative motor outcomes; and assessments of the dopaminergic system or medications. RESULTS The search yielded 237 articles, from which we identified 26 articles meeting all inclusion/exclusion criteria. The vast majority of articles were related to the use of levodopa poststroke; however, several studies assessed the effects of different medications and/or were on individuals with traumatic brain injury, spinal cord injury or cerebral palsy. CONCLUSIONS The evidence suggests that a brain injury can decrease dopamine transmission and that levodopa may have a positive effect on motor outcomes poststroke, although evidence is not conclusive or consistent. Individual variations in genes related to dopamine transmission may also influence the response to motor skill training during neurorehabilitation and the extent to which dopaminergic medications or interventions can augment that response. More rigorous safety and efficacy studies of levodopa and dopaminergic medications in stroke and particularly other neurological injuries including genetic analyses are warranted.
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Combining Dopaminergic Facilitation with Robot-Assisted Upper Limb Therapy in Stroke Survivors: A Focused Review. Am J Phys Med Rehabil 2017; 95:459-74. [PMID: 26829074 PMCID: PMC4866584 DOI: 10.1097/phm.0000000000000438] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Despite aggressive conventional therapy, lasting hemiplegia persists in a large percentage of stroke survivors. The aim of this article is to critically review the rationale behind targeting multiple sites along the motor learning network by combining robotic therapy with pharmacotherapy and virtual reality–based reward learning to alleviate upper extremity impairment in stroke survivors. Methods for personalizing pharmacologic facilitation to each individual’s unique biology are also reviewed. At the molecular level, treatment with levodopa was shown to induce long-term potentiation-like and practice-dependent plasticity. Clinically, trials combining conventional therapy with levodopa in stroke survivors yielded statistically significant but clinically unconvincing outcomes because of limited personalization, standardization, and reproducibility. Robotic therapy can induce neuroplasticity by delivering intensive, reproducible, and functionally meaningful interventions that are objective enough for the rigors of research. Robotic therapy also provides an apt platform for virtual reality, which boosts learning by engaging reward circuits. The future of stroke rehabilitation should target distinct molecular, synaptic, and cortical sites through personalized multimodal treatments to maximize motor recovery.
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Gomes-Osman J, Cortes M, Guest J, Pascual-Leone A. A Systematic Review of Experimental Strategies Aimed at Improving Motor Function after Acute and Chronic Spinal Cord Injury. J Neurotrauma 2016; 33:425-38. [PMID: 26415105 DOI: 10.1089/neu.2014.3812] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
While various approaches have been proposed in clinical trials aimed at improving motor function after spinal cord injury in humans, there is still limited information regarding the scope, methodological quality, and evidence associated with single-intervention and multi-intervention approaches. A systematic review performed using the PubMed search engine and the key words "spinal cord injury motor recovery" identified 1973 records, of which 39 were selected (18 from the search records and 21 from reference list inspection). Study phase ( clinicaltrials.org criteria) and methodological quality (Cochrane criteria) were assessed. Studies included proposed a broad range of single-intervention (encompassing cell therapies, pharmacology, electrical stimulation, rehabilitation) (encompassing cell therapies, pharmacology, electrical stimulation, rehabilitation) and multi-intervention approaches (that combined more than one strategy). The highest evidence level was for Phase III studies supporting the role of multi-intervention approaches that contained a rehabilitation component. Quality appraisal revealed that the percentage of selected studies classified with high risk of bias by Cochrane criteria was as follows: random sequence generation = 64%; allocation concealment = 77%; blinding of participants and personnel = 69%; blinding of outcome assessment = 64%; attrition = 44%; selective reporting = 44%. The current literature contains a high proportion of studies with a limited ability to measure efficacy in a valid manner because of low methodological strength in all items of the Cochrane risk of bias assessment. Recommendations to decrease bias are discussed and include increased methodological rigor in the study design and recruitment of study participants, and the use of electrophysiological and imaging measures that can assess functional integrity of the spinal cord (and may be sufficiently sensitive to detect changes that occur in response to therapeutic interventions).
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Affiliation(s)
- Joyce Gomes-Osman
- 1 Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center , Harvard Medical School, Boston, Massachusetts
| | - Mar Cortes
- 2 Non-Invasive Brain Stimulation and Human Motor Control Laboratory, Burke Medical Research Institute , Weill Cornell Medical College, White Plains, New York
| | - James Guest
- 3 Department of Neurological Surgery, The Miami Project to Cure Paralysis, Lois Pope LIFE Centre, Miller School of Medicine , Miami, Florida
| | - Alvaro Pascual-Leone
- 1 Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center , Harvard Medical School, Boston, Massachusetts
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Sharples SA, Koblinger K, Humphreys JM, Whelan PJ. Dopamine: a parallel pathway for the modulation of spinal locomotor networks. Front Neural Circuits 2014; 8:55. [PMID: 24982614 PMCID: PMC4059167 DOI: 10.3389/fncir.2014.00055] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 05/11/2014] [Indexed: 12/24/2022] Open
Abstract
The spinal cord contains networks of neurons that can produce locomotor patterns. To readily respond to environmental conditions, these networks must be flexible yet at the same time robust. Neuromodulators play a key role in contributing to network flexibility in a variety of invertebrate and vertebrate networks. For example, neuromodulators contribute to altering intrinsic properties and synaptic weights that, in extreme cases, can lead to neurons switching between networks. Here we focus on the role of dopamine in the control of stepping networks in the spinal cord. We first review the role of dopamine in modulating rhythmic activity in the stomatogastric ganglion (STG) and the leech, since work from these preparations provides a foundation to understand its role in vertebrate systems. We then move to a discussion of dopamine’s role in modulation of swimming in aquatic species such as the larval xenopus, lamprey and zebrafish. The control of terrestrial walking in vertebrates by dopamine is less studied and we review current evidence in mammals with a focus on rodent species. We discuss data suggesting that the source of dopamine within the spinal cord is mainly from the A11 area of the diencephalon, and then turn to a discussion of dopamine’s role in modulating walking patterns from both in vivo and in vitro preparations. Similar to the descending serotonergic system, the dopaminergic system may serve as a potential target to promote recovery of locomotor function following spinal cord injury (SCI); evidence suggests that dopaminergic agonists can promote recovery of function following SCI. We discuss pharmacogenetic and optogenetic approaches that could be deployed in SCI and their potential tractability. Throughout the review we draw parallels with both noradrenergic and serotonergic modulatory effects on spinal cord networks. In all likelihood, a complementary monoaminergic enhancement strategy should be deployed following SCI.
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Affiliation(s)
- Simon A Sharples
- Hotchkiss Brain Institute, University of Calgary Calgary, AB, Canada ; Department of Comparative Biology and Experimental Medicine, University of Calgary Calgary, AB, Canada
| | - Kathrin Koblinger
- Hotchkiss Brain Institute, University of Calgary Calgary, AB, Canada ; Department of Comparative Biology and Experimental Medicine, University of Calgary Calgary, AB, Canada
| | - Jennifer M Humphreys
- Hotchkiss Brain Institute, University of Calgary Calgary, AB, Canada ; Department of Comparative Biology and Experimental Medicine, University of Calgary Calgary, AB, Canada
| | - Patrick J Whelan
- Hotchkiss Brain Institute, University of Calgary Calgary, AB, Canada ; Department of Comparative Biology and Experimental Medicine, University of Calgary Calgary, AB, Canada ; Department of Physiology and Pharmacology, University of Calgary Calgary, AB, Canada ; Department of Clinical Neurosciences, University of Calgary Calgary, AB, Canada
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Abstract
The purpose of this review is to discuss the achievements and perspectives regarding rehabilitation of sensorimotor functions after spinal cord injury. In the first part we discuss clinical approaches based on neuroplasticity, a term referring to all adaptive and maladaptive changes within the sensorimotor systems triggered by a spinal cord injury. Neuroplasticity can be facilitated through the training of movements with assistance as needed, and/or by electrical stimulation techniques. The success of such training in individuals with incomplete spinal cord injury critically depends on the presence of physiological proprioceptive input to the spinal cord leading to meaningful muscle activations during movement performances. The addition of rehabilitation technology, such as robotic devices allows for longer training times and provision of feedback information regarding changes in movement performance. Nevertheless, the improvement of function by such approaches for rehabilitation is limited. In the second part, we discuss preclinical approaches to restore function by compensating for the loss of descending input to spinal networks following complete spinal cord injury. This can be achieved with stimulation of spinal networks or approaches to restore their descending input. Electrical and pharmacological stimulation of spinal neural networks is still in an experimental stage; and despite promising repair studies in animal models, translations to humans up to now have not been convincing. It is likely that combinations of techniques targeting the promotion of axonal regeneration and meaningful plasticity are necessary to advance the restoration of function. In the future, refinement of animal studies may contribute to greater translational success.
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Affiliation(s)
- Volker Dietz
- 1 Spinal Cord Injury Centre, University Hospital Balgrist, Zürich, Switzerland
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Benito J, Kumru H, Murillo N, Costa U, Medina J, Tormos JM, Pascual-Leone A, Vidal J. Motor and gait improvement in patients with incomplete spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation. Top Spinal Cord Inj Rehabil 2013; 18:106-12. [PMID: 23459246 DOI: 10.1310/sci1802-106] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To assess the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremities motor score (LEMS) and gait in patients with motor incomplete spinal cord injury (SCI). METHOD The prospective longitudinal randomized, double-blind study assessed 17 SCI patients ASIA D. We assessed LEMS, modified Ashworth Scale (MAS), 10-m walking test (10MWT), Walking Index for SCI (WISCI II) scale, step length, cadence, and Timed Up and Go (TUG) test at baseline, after the last of 15 daily sessions of rTMS and 2 weeks later. Patients were randomized to active rTMS or sham stimulation. Three patients from the initial group of 10 randomized to sham stimulation entered the active rTMS group after a 3-week washout period. Therefore a total of 10 patients completed each study condition. Both groups were homogeneous for age, gender, time since injury, etiology, and ASIA scale. Active rTMS consisted of 15 days of daily sessions of 20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold. rTMS was applied with a double cone coil to the leg motor area. RESULTS There was a significant improvement in LEMS in the active group (28.4 at baseline and 33.2 after stimulation; P = .004) but not in the sham group (29.6 at baseline, and 30.9 after stimulation; P = .6). The active group also showed significant improvements in the MAS, 10MWT, cadence, step length, and TUG, and these improvements were maintained 2 weeks later. Following sham stimulation, significant improvement was found only for step length and TUG. No significant changes were observed in the WISCI II scale in either group. CONCLUSION High-frequency rTMS over the leg motor area can improve LEMS, spasticity, and gait in patients with motor incomplete SCI.
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Affiliation(s)
- J Benito
- Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari adscrit a la Universitat Autònoma de Barcelona , Barcelona , Spain
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Marinho AR, Flett HM, Craven C, Andrea Ottensmeyer C, Parsons D, Verrier MC. Walking-related outcomes for individuals with traumatic and non-traumatic spinal cord injury inform physical therapy practice. J Spinal Cord Med 2012; 35:371-81. [PMID: 23031174 PMCID: PMC3459566 DOI: 10.1179/2045772312y.0000000038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVES To describe and compare patient demographics, inpatient lengths of stay (LOS), and walking-related functional outcomes of individuals with spinal cord injuries (SCIs) of traumatic (TSCI) and non-traumatic (NTSCI) etiologies. To contrast these features between individuals who walked from those who did not walk at discharge from inpatient rehabilitation. DESIGN Prospective observational study; comparisons between TSCI and NTSCI, walkers and non-walkers. Information collected as a pilot project within a provincial SCI informatics strategy. SETTING Rehabilitation hospital specialized for SCIs. PARTICIPANTS Adults with NTSCI (n = 31) or TSCI (n = 59) admitted to inpatient rehabilitation, 2007-2009. OUTCOME MEASURES Lower-extremity motor scores (LEMS), spinal cord independence measure version III (SCIM-III) total and mobility subscores, functional independence measure (FIM), Length of Stay (LOS) at inpatient facilities. RESULTS Groups (NTSCI vs. TSCI) did not differ in the proportion of individuals that achieved "walker" status (SCIM-III mobility indoors (MI) score ≥ 3 at rehab discharge) (P = 0.41, 48.9% overall). Inpatient LOS at both acute care and rehabilitation facilities did not differ between groups; however, TSCI non-walkers had longer inpatient rehabilitation LOS than TSCI walkers. Among walkers, improvement was shown on all three mobility subscores of the SCIM-III between admission and discharge from rehabilitation; highest significance was shown on the SCIM-III MI. Walking status at discharge (SCIM-III MI) was most strongly correlated with LEMS at rehab admission (r = 0.71, P < 0.001). CONCLUSION Walking outcomes are comparable among individuals with NTSCI vs. TSCI admitted for specialized SCI rehabilitation. Routine use of SCIM-III mobility items for assessment of walking outcome is recommended for inpatient rehabilitation.
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Affiliation(s)
- Andresa R. Marinho
- University of Toronto, Toronto, ON, Canada; and Toronto Rehabilitation Institute – UHN, Toronto, ON, Canada
| | - Heather M. Flett
- University of Toronto, Toronto, ON, Canada; and Toronto Rehabilitation Institute – UHN, Toronto, ON, Canada
| | - Catharine Craven
- University of Toronto, Toronto, ON, Canada; and Toronto Rehabilitation Institute – UHN, Toronto, ON, Canada
| | | | - Daria Parsons
- University of Toronto, Toronto, ON, Canada; and Toronto Rehabilitation Institute – UHN, Toronto, ON, Canada
| | - Molly C. Verrier
- University of Toronto, Toronto, ON, Canada; and Toronto Rehabilitation Institute – UHN, Toronto, ON, Canada,Correspondence to: Molly C. Verrier, Centre for Function and Well-Being, University of Toronto, 160-500 University Avenue, Toronto, ON, Canada M5G 1V7.
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Domingo A, Al-Yahya AA, Asiri Y, Eng JJ, Lam T. A systematic review of the effects of pharmacological agents on walking function in people with spinal cord injury. J Neurotrauma 2012; 29:865-79. [PMID: 22142289 PMCID: PMC4496059 DOI: 10.1089/neu.2011.2052] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Studies of spinalized animals indicate that some pharmacological agents may act on receptors in the spinal cord, helping to produce coordinated locomotor movement. Other drugs may help to ameliorate the neuropathological changes resulting from spinal cord injury (SCI), such as spasticity or demyelination, to improve walking. The purpose of this study was to systematically review the effects of pharmacological agents on gait in people with SCI. A keyword literature search of articles that evaluated the effects of drugs on walking after SCI was performed using the databases MEDLINE/PubMed, CINAHL, EMBASE, PsycINFO, and hand searching. Two reviewers independently evaluated each study, using the Physiotherapy Evidence Database (PEDro) tool for randomized clinical trials (RCTs), and the modified Downs & Black scale for all other studies. Results were tabulated and levels of evidence were assigned. Eleven studies met the inclusion criteria. One RCT provided Level 1 evidence that GM-1 ganglioside in combination with physical therapy improved motor scores, walking velocity, and distance better than placebo and physical therapy in persons with incomplete SCI. Multiple studies (levels of evidence 1-5) showed that clonidine and cyproheptadine may improve locomotor function and walking speed in severely impaired individuals with incomplete SCI. Gains in walking speed associated with GM-1, cyproheptadine, and clonidine are low compared to those seen with locomotor training. There was also Level 1 evidence that 4-aminopyridine and L-dopa were no better than placebo in helping to improve gait. Two Level 5 studies showed that baclofen had little to no effect on improving walking in persons with incomplete SCI. There is limited evidence that pharmacological agents tested so far would facilitate the recovery of walking after SCI. More studies are needed to better understand the effects of drugs combined with gait training on walking outcomes in people with SCI.
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Affiliation(s)
- Antoinette Domingo
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada.
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