1
|
Dietz N, Alkin V, Agarwal N, Bjurström MF, Ugiliweneza B, Wang D, Sharma M, Drazin D, Boakye M. Polypharmacy in spinal cord injury: Matched cohort analysis comparing drug classes, medical complications, and healthcare utilization metrics with 24-month follow-up. J Spinal Cord Med 2024:1-10. [PMID: 39037335 DOI: 10.1080/10790268.2024.2375892] [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: 07/23/2024] Open
Abstract
OBJECTIVE Polypharmacy in spinal cord injury (SCI) is common and predisposes patients to increased risk of adverse events. Evaluation of long-term health consequences and economic burden of polypharmacy in patients with SCI is explored. DESIGN Retrospective cohort. METHODS The IBM Marketscan Research Databases claims-based dataset was queried to search for adult patients with SCI with a 2-year follow-up. PARTICIPANTS Two matched cohorts were analyzed: those with and without polypharmacy, analyzing index hospitalization, readmissions, payments, and health outcomes. RESULTS A total of 11 569 individuals with SCI were included, of which 7235 (63%) were in the polypharmacy group who took a median of 11 separate drugs over two years. Opioid analgesics were the most common medication, present in 57% of patients with SCI meeting the criteria of polypharmacy, followed by antidepressant medications (46%) and muscle relaxants (40%). Risk of pneumonia was increased for the polypharmacy group (58%) compared to the non-polypharmacy group (45%), as were urinary tract infection (79% versus 63%), wound infection (30% versus 21%), depression (76% versus 57%), and adverse drug events (24% versus 15%) at 2 years. Combined median healthcare payments were higher in polypharmacy at 2 years ($44 333 vs. $10 937, P < .0001). CONCLUSION Majority of individuals with SCI met the criteria for polypharmacy with nearly 60% of those prescribed opioids and taking drugs from high-risk side effect profiles. Polypharmacy in SCI was associated with a greater risk of pneumonia, depression, urinary tract infections, adverse drug events, and emergency room visits over two years with four times higher overall healthcare payments at 1-year post-injury.
Collapse
Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Victoria Alkin
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Nitin Agarwal
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| | - Doniel Drazin
- Department of Neurosurgery, Pacific Northwest University of Health Sciences, Yakima, Washington, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky, USA
| |
Collapse
|
2
|
Angeli C, Rejc E, Boakye M, Herrity A, Mesbah S, Hubscher C, Forrest G, Harkema S. Targeted Selection of Stimulation Parameters for Restoration of Motor and Autonomic Function in Individuals With Spinal Cord Injury. Neuromodulation 2024; 27:645-660. [PMID: 37140522 PMCID: PMC10624649 DOI: 10.1016/j.neurom.2023.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/05/2023]
Abstract
STUDY DESIGN This is a report of methods and tools for selection of task and individual configurations targeted for voluntary movement, standing, stepping, blood pressure stabilization, and facilitation of bladder storage and emptying using tonic-interleaved excitation of the lumbosacral spinal cord. OBJECTIVES This study aimed to present strategies used for selection of stimulation parameters for various motor and autonomic functions. CONCLUSIONS Tonic-interleaved functionally focused neuromodulation targets a myriad of consequences from spinal cord injury with surgical implantation of the epidural electrode at a single location. This approach indicates the sophistication of the human spinal cord circuitry and its important role in the regulation of motor and autonomic functions in humans.
Collapse
Affiliation(s)
- Claudia Angeli
- Department of Bioengineering, University of Louisville, Louisville, KY, USA; Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA.
| | - Enrico Rejc
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Maxwell Boakye
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - April Herrity
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Department of Neurological Surgery, University of Louisville, Louisville, KY, USA; Department of Physiology, University of Louisville, Louisville, KY, USA
| | - Samineh Mesbah
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA
| | - Charles Hubscher
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Department of Anatomical Sciences and Neurobiology, University of Louisville, Louisville, KY, USA
| | - Gail Forrest
- Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Susan Harkema
- Kentucky Spinal Cord Injury Center, University of Louisville, Louisville, KY, USA; Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA; Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| |
Collapse
|
3
|
Hoover C, Schuerger W, Balser D, McCracken P, Murray TA, Morse L, Parr A, Samadani U, Netoff TI, Darrow DP. Neuromodulation Through Spinal Cord Stimulation Restores Ability to Voluntarily Cycle After Motor Complete Paraplegia. J Neurotrauma 2024; 41:1163-1171. [PMID: 36719784 DOI: 10.1089/neu.2022.0322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Abstract Epidural spinal cord stimulation (eSCS) of the lower thoracic spinal cord has been shown to partially restore volitional movement in patients with complete chronic spinal cord injury (cSCI). Combining eSCS with intensive locomotor training improves motor function, including standing and stepping, but many patients with cSCI suffer from long-standing muscle atrophy and loss of bone mineral density, which may prohibit safe implementation. Safe, accessible, and effective avenues for pairing neuromodulation with activity-based therapy remain unexplored. Cycling is one such option that can be utilized as an eSCS therapy given its low-risk and low-weight-bearing requirement. We investigated the feasibility and kinematics of motor-assisted and passive cycle-based therapy for cSCI patients with epidural spinal cord stimulation. Seven participants who underwent spinal cord stimulation surgery in the Epidural Stimulation After Neurologic Damage (E-STAND) trial (NCT03026816) participated in a cycling task using the motor assist MOTOmed Muvi 300. A factorial design was used such that participants were asked to cycle with and without conscious effort with and without stimulation. We used mixed effects models assessing maximum power output and time pedaling unassisted to evaluate the interaction between stimulation and conscious effort. Cycling was well-tolerated and we observed no adverse events, including in participants up to 17 years post-initial injury and up to 58 years old. All participants were found to be able to pedal without motor assist, which primarily occurred when stimulation and effort were applied together (p = 0.001). Additionally, the combination of stimulation and intention was significantly associated with higher maximum power production (p < 0.0001) and distance pedaled (p = 0.0001). No association was found between volitional movement and participant factors: age, time since injury, and spinal cord atrophy. With stimulation and conscious effort, all participants were able to achieve active cycling without motor assistance. Thus, our stationary cycling factorial study design demonstrated volitional movement restoration with eSCS in a diverse study population of cSCI participants. Further, motor-assist cycling was well-tolerated without any adverse events. Cycling has the potential to be a safe research assessment and physical therapy modality for cSCI patients utilizing eSCS who have a high risk of injury with weight bearing exercise. The cycling modality in this study was demonstrated to be a straightforward assessment of motor function and safe for all participants regardless of age or time since initial injury.
Collapse
Affiliation(s)
- Caleb Hoover
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Willis Schuerger
- University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - David Balser
- Department of Physical Medicine and Rehabilitation, MetroHealth Medical Center, Cleveland, Ohio, USA
| | - Patricia McCracken
- Department of Physical Medicine and Rehabilitation, Veteran Affairs, Minneapolis, Minnesota, USA
| | - Thomas A Murray
- Department of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota, USA
| | - Leslie Morse
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ann Parr
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Uzma Samadani
- Department of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Theoden I Netoff
- Department of Biomedical Engineering, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - David P Darrow
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
- Department of Surgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| |
Collapse
|
4
|
Liu J, Chen Z, Wu R, Yu H, Yang S, Xu J, Wu C, Guo Y, Hua N, Zeng X, Ma Y, Li G, Zhang L, Chen Y, Zeng Y, Ding Y, Lai B. Effects of tail nerve electrical stimulation on the activation and plasticity of the lumbar locomotor circuits and the prevention of skeletal muscle atrophy after spinal cord transection in rats. CNS Neurosci Ther 2024; 30:e14445. [PMID: 37752787 PMCID: PMC10916423 DOI: 10.1111/cns.14445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 09/28/2023] Open
Abstract
INTRODUCTION Severe spinal cord injury results in the loss of neurons in the relatively intact spinal cord below the injury area and skeletal muscle atrophy in the paralyzed limbs. These pathological processes are significant obstacles for motor function reconstruction. OBJECTIVE We performed tail nerve electrical stimulation (TNES) to activate the motor neural circuits below the injury site of the spinal cord to elucidate the regulatory mechanisms of the excitatory afferent neurons in promoting the reconstruction of locomotor function. METHODS Eight days after T10 spinal cord transection in rats, TNES was performed for 7 weeks. Behavioral scores were assessed weekly. Electrophysiological tests and double retrograde tracings were performed at week 8. RESULTS After 7 weeks of TNES treatment, there was restoration in innervation, the number of stem cells, and mitochondrial metabolism in the rats' hindlimb muscles. Double retrograde tracings of the tail nerve and sciatic nerve further confirmed the presence of synaptic connections between the tail nerve and central pattern generator (CPG) neurons in the lumbar spinal cord, as well as motor neurons innervating the hindlimb muscles. CONCLUSION The mechanisms of TNES induced by the stimulation of primary afferent nerve fibers involves efficient activation of the motor neural circuits in the lumbosacral segment, alterations of synaptic plasticity, and the improvement of muscle and nerve regeneration, which provides the structural and functional foundation for the future use of cutting-edge biological treatment strategies to restore voluntary movement of paralyzed hindlimbs.
Collapse
Affiliation(s)
- Jia‐Lin Liu
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
| | - Zheng‐Hong Chen
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Rehabilitation Medicine DepartmentThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Rong‐Jie Wu
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Shantou University Medical CollegeShantouGuangdongChina
- Department of OrthopedicsGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
| | - Hai‐Yang Yu
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of OrthopedicsGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
| | - Shang‐Bin Yang
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jing Xu
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Guangdong Provincial Key Laboratory of Brain Function and DiseaseZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Chuang‐Ran Wu
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of OrthopedicsGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
| | - Yi‐Nan Guo
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Nan Hua
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
| | - Xiang Zeng
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yuan‐Huan Ma
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Guangzhou First People's Hospital, Guangzhou Institute of Clinical Medicine, South China University of TechnologyGuangzhouGuangdongChina
| | - Ge Li
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Guangdong Provincial Key Laboratory of Pathogenesis, Targeted Prevention and Treatment of Heart DiseaseGuangdong Provincial People's Hospital(Guangdong Academy of Medical Sciences), Southern Medical UniversityGuangzhouGuangdongChina
| | - Ling Zhang
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Rehabilitation Medicine DepartmentThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yuan‐Feng Chen
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of OrthopedicsGuangdong Provincial People's Hospital, Guangdong Academy of Medical SciencesGuangzhouGuangdongChina
| | - Yuan‐Shan Zeng
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Guangdong Provincial Key Laboratory of Brain Function and DiseaseZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Co‐innovation Center of NeuroregenerationNantong UniversityNantongJiangsuChina
| | - Ying Ding
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Guangdong Provincial Key Laboratory of Brain Function and DiseaseZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Bi‐Qin Lai
- Key Laboratory for Stem Cells and Tissue Engineering (Sun Yat‐sen University), Ministry of EducationGuangzhouGuangdongChina
- Department of Histology and EmbryologyZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Guangdong Provincial Key Laboratory of Brain Function and DiseaseZhongshan School of Medicine, Sun Yat‐sen UniversityGuangzhouGuangdongChina
- Co‐innovation Center of NeuroregenerationNantong UniversityNantongJiangsuChina
| |
Collapse
|
5
|
Chalif JI, Chavarro VS, Mensah E, Johnston B, Fields DP, Chalif EJ, Chiang M, Sutton O, Yong R, Trumbower R, Lu Y. Epidural Spinal Cord Stimulation for Spinal Cord Injury in Humans: A Systematic Review. J Clin Med 2024; 13:1090. [PMID: 38398403 PMCID: PMC10889415 DOI: 10.3390/jcm13041090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Spinal cord injury (SCI) represents a major health challenge, often leading to significant and permanent sensorimotor and autonomic dysfunctions. This study reviews the evolving role of epidural spinal cord stimulation (eSCS) in treating chronic SCI, focusing on its efficacy and safety. The objective was to analyze how eSCS contributes to the recovery of neurological functions in SCI patients. (2) Methods: We utilized the PRISMA guidelines and performed a comprehensive search across MEDLINE/PubMed, Embase, Web of Science, and IEEE Xplore databases up until September 2023. We identified studies relevant to eSCS in SCI and extracted assessments of locomotor, cardiovascular, pulmonary, and genitourinary functions. (3) Results: A total of 64 studies encompassing 306 patients were identified. Studies investigated various stimulation devices, parameters, and rehabilitation methods. Results indicated significant improvements in motor function: 44% of patients achieved assisted or independent stepping or standing; 87% showed enhanced muscle activity; 65% experienced faster walking speeds; and 80% improved in overground walking. Additionally, eSCS led to better autonomic function, evidenced by improvements in bladder and sexual functions, airway pressures, and bowel movements. Notable adverse effects included device migration, infections, and post-implant autonomic dysreflexia, although these were infrequent. (4) Conclusion: Epidural spinal cord stimulation is emerging as an effective and generally safe treatment for chronic SCI, particularly when combined with intensive physical rehabilitation. Future research on standardized stimulation parameters and well-defined therapy regimens will optimize benefits for specific patient populations.
Collapse
Affiliation(s)
- J. I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.I.C.); (V.S.C.); (B.J.)
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
| | - V. S. Chavarro
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.I.C.); (V.S.C.); (B.J.)
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
- Department of Physical Medicine and Rehabilitation, Spaulding Hospital Cambridge, Cambridge, MA 02115, USA
| | - E. Mensah
- Chan School of Public Health, Harvard University, Boston, MA 02115, USA;
| | - B. Johnston
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.I.C.); (V.S.C.); (B.J.)
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
| | - D. P. Fields
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA 15261, USA;
| | - E. J. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.I.C.); (V.S.C.); (B.J.)
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
| | - M. Chiang
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
- Department of Physical Medicine and Rehabilitation, Spaulding Hospital Cambridge, Cambridge, MA 02115, USA
- Department of Anesthesiology Perioperative and Pain Management, Brigham and Women’s Hospital, Boston, MA 02115, USA;
| | - O. Sutton
- Department of Anesthesiology Perioperative and Pain Management, Brigham and Women’s Hospital, Boston, MA 02115, USA;
| | - R. Yong
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
- Department of Anesthesiology Perioperative and Pain Management, Brigham and Women’s Hospital, Boston, MA 02115, USA;
| | - R. Trumbower
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
- Department of Physical Medicine and Rehabilitation, Spaulding Hospital Cambridge, Cambridge, MA 02115, USA
| | - Y. Lu
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA 02115, USA; (J.I.C.); (V.S.C.); (B.J.)
- Harvard Medical School, Boston, MA 02115, USA; (M.C.); (R.Y.); (R.T.)
| |
Collapse
|
6
|
Stewart AN, Kumari R, Bailey WM, Glaser EP, Bosse-Joseph CC, Park KA, Hammers GV, Wireman OH, Gensel JC. PTEN knockout using retrogradely transported AAVs transiently restores locomotor abilities in both acute and chronic spinal cord injury. Exp Neurol 2023; 368:114502. [PMID: 37558155 PMCID: PMC10498341 DOI: 10.1016/j.expneurol.2023.114502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/07/2023] [Accepted: 08/07/2023] [Indexed: 08/11/2023]
Abstract
Restoring function in chronic stages of spinal cord injury (SCI) has often been met with failure or reduced efficacy when regenerative strategies are delayed past the acute or sub-acute stages of injury. Restoring function in the chronically injured spinal cord remains a critical challenge. We found that a single injection of retrogradely transported adeno-associated viruses (AAVrg) to knockout the phosphatase and tensin homolog protein (PTEN) in chronic SCI can effectively target both damaged and spared axons and transiently restore locomotor functions in near-complete injury models. AAVrg's were injected to deliver cre recombinase and/or a red fluorescent protein (RFP) under the human Synapsin 1 promoter (hSyn1) into the spinal cords of C57BL/6 PTENFloxΔ/Δ mice to knockout PTEN (PTEN-KO) in a severe thoracic SCI crush model at both acute and chronic time points. PTEN-KO improved locomotor abilities in both acute and chronic SCI conditions over a 9-week period. Regardless of whether treatment was initiated at the time of injury (acute), or three months after SCI (chronic), mice with limited hindlimb joint movement gained hindlimb weight support after treatment. Interestingly, functional improvements were not sustained beyond 9 weeks coincident with a loss of RFP reporter-gene expression and a near-complete loss of treatment-associated functional recovery by 6 months post-treatment. Treatment effects were also specific to severely injured mice; animals with weight support at the time of treatment lost function over a 6-month period. Retrograde tracing with Fluorogold revealed viable neurons throughout the motor cortex despite a loss of RFP expression at 9 weeks post-PTEN-KO. However, few Fluorogold labeled neurons were detected within the motor cortex at 6 months post-treatment. BDA labeling from the motor cortex revealed a dense corticospinal tract (CST) bundle in all groups except chronically treated PTEN-KO mice, indicating a potential long-term toxic effect of PTEN-KO to neurons in the motor cortex which was corroborated by a loss of β-tubulin III labeling above the lesion within spinal cords after PTEN-KO. PTEN-KO mice had significantly more β-tubulin III labeled axons within the lesion when treatment was delivered acutely, but not chronically post-SCI. In conclusion, we have found that using AAVrg's to knockout PTEN is an effective manipulation capable of restoring motor functions in chronic SCI and can enhance axon growth of currently unidentified axon populations when delivered acutely after injury. However, the long-term consequences of PTEN-KO on neuronal health and viability should be further explored.
Collapse
Affiliation(s)
- Andrew N Stewart
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA.
| | - Reena Kumari
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - William M Bailey
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - Ethan P Glaser
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - Christopher C Bosse-Joseph
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - Kennedy A Park
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - Gabrielle V Hammers
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - Olivia H Wireman
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA
| | - John C Gensel
- Department of Physiology, University of Kentucky, Lexington, KY 40536, USA; Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, KY 40536, USA; College of Medicine, University of Kentucky, Lexington, KY 40536, USA.
| |
Collapse
|
7
|
Stewart AN, Kumari R, Bailey WM, Glaser EP, Hammers GV, Wireman OH, Gensel JC. PTEN knockout using retrogradely transported AAVs restores locomotor abilities in both acute and chronic spinal cord injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.17.537179. [PMID: 37131840 PMCID: PMC10153160 DOI: 10.1101/2023.04.17.537179] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Restoring function in chronic stages of spinal cord injury (SCI) has often been met with failure or reduced efficacy when regenerative strategies are delayed past the acute or sub-acute stages of injury. Restoring function in the chronically injured spinal cord remains a critical challenge. We found that a single injection of retrogradely transported adeno-associated viruses (AAVrg) to knockout the phosphatase and tensin homolog protein (PTEN) in chronic SCI can effectively target both damaged and spared axons and restore locomotor functions in near-complete injury models. AAVrg's were injected to deliver cre recombinase and/or a red fluorescent protein (RFP) under the human Synapsin 1 promoter (hSyn1) into the spinal cords of C57BL/6 PTEN FloxΔ / Δ mice to knockout PTEN (PTEN-KO) in a severe thoracic SCI crush model at both acute and chronic time points. PTEN-KO improved locomotor abilities in both acute and chronic SCI conditions over a 9-week period. Regardless of whether treatment was initiated at the time of injury (acute), or three months after SCI (chronic), mice with limited hindlimb joint movement gained hindlimb weight support after treatment. Interestingly, functional improvements were not sustained beyond 9 weeks coincident with a loss of RFP reporter-gene expression and a near-complete loss of treatment-associated functional recovery by 6 months post-treatment. Treatment effects were also specific to severely injured mice; animals with weight support at the time of treatment lost function over a 6-month period. Retrograde tracing with Fluorogold revealed viable neurons throughout the motor cortex despite a loss of RFP expression at 9 weeks post-PTEN-KO. However, few Fluorogold labeled neurons were detected within the motor cortex at 6 months post-treatment. BDA labeling from the motor cortex revealed a dense corticospinal tract (CST) bundle in all groups except chronically treated PTEN-KO mice indicating a potential long-term toxic effect of PTEN-KO to neurons in the motor cortex. PTEN-KO mice had significantly more β - tubulin III labeled axons within the lesion when treatment was delivered acutely, but not chronically post-SCI. In conclusion, we have found that using AAVrg's to knockout PTEN is an effective manipulation capable of restoring motor functions in chronic SCI and can enhance axon growth of currently unidentified axon populations when delivered acutely after injury. However, the long-term consequences of PTEN-KO may exert neurotoxic effects.
Collapse
Affiliation(s)
- Andrew N. Stewart
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - Reena Kumari
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - William M. Bailey
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - Ethan P. Glaser
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - Gabrielle V. Hammers
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - Olivia H. Wireman
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
| | - John C. Gensel
- Department of Physiology, University of Kentucky, Lexington, Kentucky 40536, USA
- Spinal Cord and Brain Injury Research Center, University of Kentucky, Lexington, Kentucky 40536, USA
- College of Medicine, University of Kentucky, Lexington, Kentucky 40536, USA
| |
Collapse
|
8
|
Boakye M, Ball T, Dietz N, Sharma M, Angeli C, Rejc E, Kirshblum S, Forrest G, Arnold FW, Harkema S. Spinal cord epidural stimulation for motor and autonomic function recovery after chronic spinal cord injury: A case series and technical note. Surg Neurol Int 2023; 14:87. [PMID: 37025529 PMCID: PMC10070319 DOI: 10.25259/sni_1074_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/14/2023] [Indexed: 03/19/2023] Open
Abstract
Background:
Traumatic spinal cord injury (tSCI) is a debilitating condition, leading to chronic morbidity and mortality. In recent peer-reviewed studies, spinal cord epidural stimulation (scES) enabled voluntary movement and return of over-ground walking in a small number of patients with motor complete SCI. Using the most extensive case series (n = 25) for chronic SCI, the present report describes our motor and cardiovascular and functional outcomes, surgical and training complication rates, quality of life (QOL) improvements, and patient satisfaction results after scES.
Methods:
This prospective study occurred at the University of Louisville from 2009 to 2020. scES interventions began 2–3 weeks after surgical implantation of the scES device. Perioperative complications were recorded as well as long-term complications during training and device related events. QOL outcomes and patient satisfaction were evaluated using the impairment domains model and a global patient satisfaction scale, respectively.
Results:
Twenty-five patients (80% male, mean age of 30.9 ± 9.4 years) with chronic motor complete tSCI underwent scES using an epidural paddle electrode and internal pulse generator. The interval from SCI to scES implantation was 5.9 ± 3.4 years. Two participants (8%) developed infections, and three additional patients required washouts (12%). All participants achieved voluntary movement after implantation. A total of 17 research participants (85%) reported that the procedure either met (n = 9) or exceeded (n = 8) their expectations, and 100% would undergo the operation again.
Conclusion:
scES in this series was safe and achieved numerous benefits on motor and cardiovascular regulation and improved patient-reported QOL in multiple domains, with a high degree of patient satisfaction. The multiple previously unreported benefits beyond improvements in motor function render scES a promising option for improving QOL after motor complete SCI. Further studies may quantify these other benefits and clarify scES’s role in SCI patients.
Collapse
Affiliation(s)
- Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Tyler Ball
- Department of Neurosurgery, Vanderbilt University, Nashville,
| | - Nicholas Dietz
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Claudia Angeli
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Enrico Rejc
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| | - Steven Kirshblum
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Gail Forrest
- Department of Physical Medicine Rehabilitation, Rutgers, Newark, New Jersey,
| | - Forest W. Arnold
- Department of Infectious Diseases, University of Louisville, Louisville, United States
| | - Susan Harkema
- Department of Neurosurgery, University of Louisville, Louisville, Kentucky,
| |
Collapse
|
9
|
Trolle C, Goldberg E, Linnman C. Spinal cord atrophy after spinal cord injury - A systematic review and meta-analysis. Neuroimage Clin 2023; 38:103372. [PMID: 36931004 PMCID: PMC10026037 DOI: 10.1016/j.nicl.2023.103372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/12/2023] [Accepted: 03/06/2023] [Indexed: 03/12/2023]
Abstract
Cervical spinal cord atrophy occurs after spinal cord injury. The atrophy and how level of injury affects atrophy differs between studies. A systematic review and metaanalysis were done after systematic searches of PubMed, CINAHL, APA PsycInfo and Web of Science. English language original studies analyzing MRI cervical spinal cord cross-sectional area in adults with spinal cord injury were included. Atrophy and correlation between injury level and atrophy were estimated with random-effects models, standardized mean differences, and 95% confidence intervals. 24 studies were identified. 13/24 studies had low risk of bias. Cord atrophy meta-analysis of 18 articles corresponded to a standardized mean difference of -1.48 (95% CI -1.78 to -1.19) with moderate to large interstudy heterogeneity. Logarithmic time since injury influenced heterogeneity. Longitudinal atrophy was best described by a logarithmic model, indicating that rate of spinal atrophy decreases over time. Meta-correlation of eight studies indicated more severe atrophy in more rostral injuries (0.41, 95% CI 0.20-0.59). Larger and preferably longitudinal studies, data sharing, and standardized protocols are warranted.
Collapse
Affiliation(s)
- Carl Trolle
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA; Department of Medical Sciences, Rehabilitation Medicine, Uppsala University, Uppsala, Sweden.
| | - Estee Goldberg
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Clas Linnman
- Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
10
|
Li Z, Rong YL, Zhang YS. MiR-33-5p alleviates spinal cord injury in rats and protects PC12 cells from lipopolysaccharide-induced apoptosis. Kaohsiung J Med Sci 2023; 39:52-60. [PMID: 36354186 DOI: 10.1002/kjm2.12610] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 11/11/2022] Open
Abstract
MicroRNAs (miRNAs) exert critical effects in spinal cord injury (SCI). The miR-33-5p level is found to be lower in rats with SCI compared with that in control (untreated) and sham-operated (laminectomy but no contusion) rats. Therefore, we investigated the biological functions of miR-33-5p and related mechanisms in SCI pathogenesis and development. An in vivo SCI model and a lipopolysaccharide (LPS)-induced cell model of SCI were established. A downregulated level of miR-33-5p in experimental SCI and in LPS-treated PC12 cells was revealed by reverse transcriptase-quantitative polymerase chain reaction (RT-qPCR). MiR-33-5p upregulation alleviated the leakage of the blood-spinal cord barrier (BSCB) induced by SCI and improved the neurological functions of SCI rats, as evidenced by the Basso, Beattie, and Bresnahan (BBB) scores and Evans blue staining. The regulatory relationship between miR-33-5p and Rps6kb1 was verified by luciferase reporter assays, which demonstrated that miR-33-5p bound to the Rps6kb1 3'UTR. Moreover, as MTT assays and flow cytometry showed, the suppressive effects of miR-33-5p upregulation on cell apoptosis were attenuated by Rps6kb1 upregulation. In conclusion, miR-33-5p ameliorates SCI in rats and inhibits the LPS-induced apoptosis of PC12 cells.
Collapse
Affiliation(s)
- Zhe Li
- Department of Second Orthopaedic Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| | - Yan-Long Rong
- Department of Orthopedic, TieMei General Hospital of Liaoning Province Health Industrial Group, Tieling, Liaoning, China
| | - Yuan-Shi Zhang
- Department of Second Orthopaedic Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, Liaoning, China
| |
Collapse
|
11
|
Dietz N, Wagers S, Harkema SJ, D'Amico JM. Intrathecal and Oral Baclofen Use in Adults With Spinal Cord Injury: A Systematic Review of Efficacy in Spasticity Reduction, Functional Changes, Dosing, and Adverse Events. Arch Phys Med Rehabil 2023; 104:119-131. [PMID: 35750207 DOI: 10.1016/j.apmr.2022.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the efficacy, dosing, and safety profiles of intrathecal and oral baclofen in treating spasticity after spinal cord injury (SCI). DATA SOURCES PubMed and Cochrane Databases were searched from 1970-2018 with keywords baclofen, spinal cord injury, and efficacy. STUDY SELECTION The database search yielded 588 sources and 10 additional relevant publications. After removal of duplicates, 398 publications were screened. DATA EXTRACTION Data were extracted using the following population, intervention, comparator, outcomes, and study designs criteria: studies including adult patients with SCI with spasticity; the intervention could be oral or intrathecal administration of baclofen; selection was inclusive for control groups, surgical management, rehabilitation, and alternative pharmaceutical agents; outcomes were efficacy, dosing, and adverse events. Randomized controlled trials, observational studies, and case reports were included. Meta-analyses and systematic reviews were excluded. DATA SYNTHESIS A total of 98 studies were included with 1943 patients. Only 4 randomized, double-blinded, and placebo-controlled trials were reported. Thirty-nine studies examined changes in the Modified Ashworth Scale (MAS; 34 studies) and Penn Spasm scores (Penn Spasm Frequency; 19 studies), with average reductions of 1.7±1.3 and 1.6±1.4 in individuals with SCI, respectively. Of these data, a total of 6 of the 34 studies (MAS) and 2 of the 19 studies (Penn Spasm Frequency) analyzed oral baclofen. Forty-three studies addressed adverse events with muscle weakness and fatigue frequently reported. CONCLUSIONS Baclofen is the most commonly-prescribed antispasmodic after SCI. Surprisingly, there remains a significant lack of large, placebo-controlled, double-blinded clinical trials, with most efficacy data arising from small studies examining treatment across different etiologies. In the studies reviewed, baclofen effectively improved spasticity outcome measures, with increased efficacy through intrathecal administration. Few studies assessed how reduced neural excitability affected residual motor function and activities of daily living. A host of adverse events were reported that may negatively affect quality of life. Comparative randomized controlled trials of baclofen and alternative treatments are warranted because these have demonstrated promise in relieving spasticity with reduced adverse events and without negatively affecting residual motor function.
Collapse
Affiliation(s)
- Nicholas Dietz
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Sarah Wagers
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Susan J Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Jessica M D'Amico
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY.
| |
Collapse
|
12
|
Mesbah S, Herrity A, Ugiliweneza B, Angeli C, Gerasimenko Y, Boakye M, Harkema S. Neuroanatomical mapping of the lumbosacral spinal cord in individuals with chronic spinal cord injury. Brain Commun 2022; 5:fcac330. [PMID: 36632181 PMCID: PMC9825531 DOI: 10.1093/braincomms/fcac330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 09/27/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
With emerging applications of spinal cord electrical stimulation in restoring autonomic and motor function after spinal cord injury, understanding the neuroanatomical substrates of the human spinal cord after spinal cord injury using neuroimaging techniques can play a critical role in optimizing the outcomes of these stimulation-based interventions. In this study, we have introduced a neuroimaging acquisition and analysis protocol of the spinal cord in order to identify: (i) spinal cord levels at the lumbosacral enlargement using nerve root tracing; (ii) variability in the neuroanatomical characteristics of the spinal cord among individuals; (iii) location of the epidural stimulation paddle electrode and contacts with respect to the spinal cord levels at lumbosacral enlargement; and (iv) the links between the anatomical levels of stimulation and the corresponding neurophysiological motor responses. Twelve individuals with chronic, motor complete spinal cord injury implanted with a spinal cord epidural stimulator were included in the study (age: 34 ± 10.9 years, sex: 10 males, 2 females, time since injury: 8.2 ± 9.9 years, American Spinal Injury Association Impairment Scale: 6 A, 6 B). High-resolution MRI scans of the spinal cord were recorded pre-implant. An analysis of neuroanatomical substrates indicates that the length of the spinal column and spinal cord, location of the conus tip and the relationship between the spinal cord levels and vertebral levels, particularly at the lumbosacral enlargement, are variable across individuals. There is no statistically significant correlation between the length of the spinal column and the length of the spinal cord. The percentage of volumetric coverage of the lumbosacral spinal cord by the epidural stimulation paddle electrode ranges from 33.4 to 90.4% across participants. The location of the spinal cord levels with respect to the electrode contacts varies across individuals and impacts the recruitment patterns of neurophysiological responses. Finally, MRI-based spinal cord modelling can be used as a guide for the prediction and preplanning of optimum epidural stimulation paddle placement prior to the implant surgery to ensure maximizing functional outcomes. These findings highlight the crucial role that the neuroanatomical characteristics of the spinal cord specific to each individual play in achieving maximum functional benefits with spinal cord electrical stimulation.
Collapse
Affiliation(s)
- Samineh Mesbah
- Correspondence to: Samineh Mesbah, PhD 220 Abraham Flexner, Louisville, KY 40202, USA E-mail:
| | - April Herrity
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA,Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA,Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA,Department of Health Management and Systems Science, University of Louisville, Louisville, KY 40202, USA
| | - Claudia Angeli
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA,Department of Bioengineering, University of Louisville, Louisville, KY 40292, USA,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY 40202, USA
| | - Yury Gerasimenko
- Department of Physiology and Biophysics, University of Louisville, Louisville, KY 40202, USA,Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg 199034, Russia
| | - Maxwell Boakye
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA,Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
| | - Susan Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA,Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY 40202, USA
| |
Collapse
|
13
|
Dietz N, Vaitheesh Jaganathan, Alkin V, Mettille J, Boakye M, Drazin D. Machine learning in clinical diagnosis, prognostication, and management of acute traumatic spinal cord injury (SCI): A systematic review. J Clin Orthop Trauma 2022; 35:102046. [PMID: 36425281 PMCID: PMC9678757 DOI: 10.1016/j.jcot.2022.102046] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/23/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022] Open
Abstract
Background Machine learning has been applied to improve diagnosis and prognostication of acute traumatic spinal cord injury. We investigate potential for clinical integration of machine learning in this patient population to navigate variability in injury and recovery. Materials and methods We performed a systematic review using PRISMA guidelines through PubMed database to identify studies that use machine learning algorithms for clinical application toward improvements in diagnosis, management, and predictive modeling. Results Of the 132 records identified, a total of 13 articles met inclusion criteria and were included in final analysis. Of the 13 articles, 5 focused on diagnostic accuracy and 8 were related to prognostication or management of traumatic spinal cord injury. Across studies, 1983 patients with spinal cord injury were evaluated with most classifying as ASIA C or D. Retrospective designs were used in 10 of 13 studies and 3 were prospective. Studies focused on MRI evaluation and segmentation for diagnostic accuracy and prognostication, investigation of mean arterial pressure in acute care and intraoperative settings, prediction of ambulatory and functional ability, chronic complication prevention, and psychological quality of life assessments. Decision tree, random forests (RF), support vector machines (SVM), hierarchical cluster tree analysis (HCTA), artificial neural networks (ANN), convolutional neural networks (CNN) machine learning subtypes were used. Conclusions Machine learning represents a platform technology with clinical application in traumatic spinal cord injury diagnosis, prognostication, management, rehabilitation, and risk prevention of chronic complications and mental illness. SVM models showed improved accuracy when compared to other ML subtypes surveyed. Inherent variability across patients with SCI offers unique opportunity for ML and personalized medicine to drive desired outcomes and assess risks in this patient population.
Collapse
Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Vaitheesh Jaganathan
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | | | - Jersey Mettille
- Department of Anesthesia, University of Louisville, Louisville, KY, USA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, 200 Abraham Flexner Hwy, Louisville, KY, 40202, USA
| | - Doniel Drazin
- Department of Neurosurgery, Providence Regional Medical Center Everett, Everett, WA, USA
| |
Collapse
|
14
|
Putrino D, Krakauer JW. Neurotechnology’s Prospects for Bringing About Meaningful Reductions in Neurological Impairment. Neurorehabil Neural Repair 2022:15459683221137341. [DOI: 10.1177/15459683221137341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Here we report and comment on the magnitudes of post-stroke impairment reduction currently observed using new neurotechnologies. We argue that neurotechnology’s best use case is impairment reduction as this is neither the primary strength nor main goal of conventional rehabilitation, which is better at targeting the activity and participation levels of the ICF. The neurotechnologies discussed here can be divided into those that seek to be adjuncts for enhancing conventional rehabilitation, and those that seek to introduce a novel behavioral intervention altogether. Examples of the former include invasive and non-invasive brain stimulation. Examples of the latter include robotics and some forms of serious gaming. We argue that motor learning and training-related recovery are conceptually and mechanistically distinct. Based on our survey of recent results, we conclude that large reductions in impairment will need to begin with novel forms of high dose and high intensity behavioral intervention that are qualitatively different to conventional rehabilitation. Adjunct forms of neurotechnology, if they are going to be effective, will need to piggyback on these new behavioral interventions.
Collapse
Affiliation(s)
- David Putrino
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John W. Krakauer
- Departments of Neurology, Neuroscience, and Physical Medicine & Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
15
|
The 2021 yearbook of Neurorestoratology. JOURNAL OF NEURORESTORATOLOGY 2022. [DOI: 10.1016/j.jnrt.2022.100008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
16
|
Mansour NM, Peña Pino I, Freeman D, Carrabre K, Venkatesh S, Darrow D, Samadani U, Parr AM. Advances in Epidural Spinal Cord Stimulation to Restore Function after Spinal Cord Injury: History and Systematic Review. J Neurotrauma 2022; 39:1015-1029. [PMID: 35403432 DOI: 10.1089/neu.2022.0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Epidural spinal cord stimulation (eSCS) has been recently recognized as a potential therapy for chronic spinal cord injury (SCI). eSCS has been shown to uncover residual pathways within the damaged spinal cord. The purpose of this review is to summarize the key findings to date regarding the use of eSCS in SCI. Searches were carried out using MEDLINE, EMBASE, and Web of Science database and reference lists of the included articles. A combination of medical subject heading terms and keywords was used to find studies investigating the use of eSCS in SCI patients to facilitate volitional movement and to restore autonomic function. The risk of bias was assessed using Risk Of Bias In Non-Randomized Studies of Interventions tool for nonrandomized studies. We were able to include 40 articles that met our eligibility criteria. The studies included a total of 184 patient experiences with incomplete or complete SCI. The majority of the studies used the Medtronic 16 paddle lead. Around half of the studies reported lead placement between T11- L1. We included studies that assessed motor (n = 28), autonomic (n = 13), and other outcomes (n = 10). The majority of the studies reported improvement in outcomes assessed. The wide range of included outcomes demonstrates the effectiveness of eSCS in treating a diverse SCI population. However, the current studies cannot definitively conclude which patients benefit the most from this intervention. Further study in this area is needed to allow improvement of the eSCS technology and allow it to be more widely available for chronic SCI patients.
Collapse
Affiliation(s)
- Nadine M Mansour
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Isabela Peña Pino
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - David Freeman
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Kailey Carrabre
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Shivani Venkatesh
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - David Darrow
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Neurosurgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Uzma Samadani
- Department of Bioinformatics and Computational Biology, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Neurosurgery, VA Healthcare System, Minneapolis, Minnesota, USA
| | - Ann M Parr
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
- Division of Neurosurgery, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| |
Collapse
|
17
|
Historical development and contemporary use of neuromodulation in human spinal cord injury. Curr Opin Neurol 2022; 35:536-543. [PMID: 35856918 DOI: 10.1097/wco.0000000000001080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW There is a long history of neuromodulation of the spinal cord after injury in humans with recent momentum of studies showing evidence for therapeutic potential. Nonrandomized, mechanistic, hypothesis-driven, small cohort, epidural stimulation proof of principle studies provide insight into the human spinal circuitry functionality and support the pathway toward clinical treatments. RECENT FINDINGS Individuals living with spinal cord injury can recover motor, cardiovascular, and bladder function even years after injury using neuromodulation. Integration of continuous feedback from sensory information, task-specific training, and optimized excitability state of human spinal circuitry are critical spinal mechanisms. Neuromodulation activates previously undetectable residual supraspinal pathways to allow intentional (voluntary) control of motor movements. Further discovery unveiled the human spinal circuitry integrated regulatory control of motor and autonomic systems indicating the realistic potential of neuromodulation to improve the capacity incrementally, but significantly for recovery after severe spinal cord injury. SUMMARY The discovery that both motor and autonomic function recovers with lumbosacral spinal cord placement of the electrode reveals exciting avenues for a synergistic overall improvement in function, health, and quality of life for those who have been living with the consequences of spinal cord injury even for decades.
Collapse
|
18
|
Herrity AN, Aslan SC, Mesbah S, Siu R, Kalvakuri K, Ugiliweneza B, Mohamed A, Hubscher CH, Harkema SJ. Targeting bladder function with network-specific epidural stimulation after chronic spinal cord injury. Sci Rep 2022; 12:11179. [PMID: 35778466 PMCID: PMC9249897 DOI: 10.1038/s41598-022-15315-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/22/2022] [Indexed: 11/20/2022] Open
Abstract
Profound dysfunctional reorganization of spinal networks and extensive loss of functional continuity after spinal cord injury (SCI) has not precluded individuals from achieving coordinated voluntary activity and gaining multi-systemic autonomic control. Bladder function is enhanced by approaches, such as spinal cord epidural stimulation (scES) that modulates and strengthens spared circuitry, even in cases of clinically complete SCI. It is unknown whether scES parameters specifically configured for modulating the activity of the lower urinary tract (LUT) could improve both bladder storage and emptying. Functional bladder mapping studies, conducted during filling cystometry, identified specific scES parameters that improved bladder compliance, while maintaining stable blood pressure, and enabled the initiation of voiding in seven individuals with motor complete SCI. Using high-resolution magnetic resonance imaging and finite element modeling, specific neuroanatomical structures responsible for modulating bladder function were identified and plotted as heat maps. Data from this pilot clinical trial indicate that scES neuromodulation that targets bladder compliance reduces incidences of urinary incontinence and provides a means for mitigating autonomic dysreflexia associated with bladder distention. The ability to initiate voiding with targeted scES is a key step towards regaining volitional control of LUT function, advancing the application and adaptability of scES for autonomic function.
Collapse
Affiliation(s)
- April N Herrity
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA.
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.
- Department of Physiology, University of Louisville, Louisville, KY, USA.
| | - Sevda C Aslan
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Samineh Mesbah
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Ricardo Siu
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Karthik Kalvakuri
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
- Department of Health Sciences, University of Louisville, Louisville, KY, USA
| | - Ahmad Mohamed
- Department of Urology, University of Louisville, Louisville, KY, USA
| | - Charles H Hubscher
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Anatomical Sciences and Neurobiology, University of Louisville, Louisville, KY, USA
| | - Susan J Harkema
- Kentucky Spinal Cord Injury Research Center, Department of Neurological Surgery, The University of Louisville, 220 Abraham Flexner Way, Suite 1518, Louisville, KY, 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| |
Collapse
|
19
|
Zhang X, Song YC, Yang DG, Liu HW, Liu SH, Li XB, Li JJ. The Effect of Vocal Intonation Therapy on Vocal Dysfunction in Patients With Cervical Spinal Cord Injury: A Randomized Control Trial. Front Neurosci 2022; 16:860127. [PMID: 35784833 PMCID: PMC9241375 DOI: 10.3389/fnins.2022.860127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
In this study, the vocal intonation therapy (VIT) was compared with the standard respiratory therapy for people suffering from respiratory dysfunction as a result of cervical spinal cord injury (CSCI) to observe its effect on vocal quality. Thirty patients with vocal dysfunction after CSCI with the injury time of more than 3 months were screened for inclusion in the trial, and 18 patients completed the 12-weeks, each participant had 60 sessions in total in the clinical trial. All patients were allocated to the intervention group or the control group. The intervention group received VIT training and the control group received respiratory phonation therapy. Both groups were trained by professional therapists, and the training time was 30 min/day, 5 days/week, for 60 sessions for each group in a total of 12 weeks. In the Baseline (T0), mid-intervention period (after 6 weeks, T1), and after intervention (after 12 weeks, T2), the vocal quality of the two groups of patients was tested with a computer-aided real-time audio analyzer 2.1.6 (Adobe Systems, United States) for Sing-SPL (p < 0.0001), Speech-SPL (p < 0.0001), SNL (p < 0.0001), and F0 (p < 0.0001) of the intervention group were significantly improved compared with the control group. In comparing the spectrometry analysis of vocal quality for the 2 groups of participants, there was a significant difference in the results of Sing-SPL and Speech-SPL acoustic analysis in the intervention group of patients at T2 (after 12 weeks) compared to the control group. Vocal intonation therapy—music therapy can improve the speech sound quality of cervical CSCI patients and provide CSCI patients with a practical, highly operable treatment that has both functional training effects and can bring a pleasant experience that can be promoted in the medical field. This study was approved by the Ethics Committee of China Rehabilitation Research Center (CRRC) (approval No. 2019-83-1) on May 20th, 2019. It was registered with the National Health Security Information Platform, medical research registration, and filing information system (Registration No. MR-11-21-011802) on January 28th, 2021.
Collapse
Affiliation(s)
- Xiaoying Zhang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - Yi-Chuan Song
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - De-Gang Yang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Hong-Wei Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Department of Spinal and Neural Functional Reconstruction, China Rehabilitation Research Center, Beijing, China
| | - Song-Huai Liu
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- Music Therapy Center, China Rehabilitation Research Center, Beijing, China
| | - Xiao-Bing Li
- Laboratory of Music Artificial Intelligence, Central Conservatory of Music, Beijing, China
- *Correspondence: Xiao-Bing Li,
| | - Jian-Jun Li
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China
- China Rehabilitation Science Institute, Beijing, China
- Beijing Key Laboratory of Neural Injury and Rehabilitation, Beijing, China
- Center of Neural Injury and Repair, Beijing Institute for Brain Disorders, Beijing, China
- Jian-Jun Li,
| |
Collapse
|
20
|
Spinal cord imaging markers and recovery of standing with epidural stimulation in individuals with clinically motor complete spinal cord injury. Exp Brain Res 2021; 240:279-288. [PMID: 34854934 DOI: 10.1007/s00221-021-06272-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 10/20/2021] [Indexed: 02/04/2023]
Abstract
Spinal cord epidural stimulation (scES) is an intervention to restore motor function in those with severe spinal cord injury (SCI). Spinal cord lesion characteristics assessed via magnetic resonance imaging (MRI) may contribute to understand motor recovery. This study assessed relationships between standing ability with scES and spared spinal cord tissue characteristics at the lesion site. We hypothesized that the amount of lateral spared cord tissue would be related to independent extension in the ipsilateral lower limb. Eleven individuals with chronic, clinically motor complete SCI underwent spinal cord MRI, and were subsequently implanted with scES. Standing ability and lower limb activation patterns were assessed during an overground standing experiment with scES. This assessment occurred prior to any activity-based intervention with scES. Lesion hyperintensity was segmented from T2 axial images, and template-based analysis was used to estimate spared tissue in anterior, posterior, right, and left spinal cord regions. Regression analysis was used to assess relationships between imaging and standing outcomes. Total volume of spared tissue was related to left (p = 0.007), right (p = 0.005), and bilateral (p = 0.011) lower limb extension. Spared tissue in the left cord region was related to left lower limb extension (p = 0.019). A positive trend (p = 0.138) was also observed between right spared cord tissue and right lower limb extension. In this study, MRI measures of spared spinal cord tissue were significantly related to standing outcomes with scES. These preliminary results warrant future investigation of roles of supraspinal input and MRI-detected spared spinal cord tissue on lower limb motor responsiveness to scES.
Collapse
|
21
|
Li Z, Wang Q, Hu H, Zheng W, Gao C. Research advances of biomaterials-based microenvironment-regulation therapies for repair and regeneration of spinal cord injury. Biomed Mater 2021; 16. [PMID: 34384071 DOI: 10.1088/1748-605x/ac1d3c] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/12/2021] [Indexed: 12/15/2022]
Abstract
Traumatic spinal cord injury (SCI) usually results in restricted behaviour recovery and even life-changing paralysis, accompanied with numerous complications. Pathologically, the initial injuries trigger a series of secondary injuries, leading to an expansion of lesion site, a mass of neuron loss, and eventual failure of endogenous axon regeneration. As the advances rapidly spring up in regenerative medicine and tissue engineering biomaterials, regulation of these secondary injuries becomes possible, shedding a light on normal functional restoration. The successful tissue regeneration lies in proper regulation of the inflammatory microenvironment, including the inflammatory immune cells and inflammatory factors that lead to oxidative stress, inhibitory glial scar and neuroexcitatory toxicity. Specifically, the approaches based on microenvironment-regulating biomaterials have shown great promise in the repair and regeneration of SCI. In this review, the pathological inflammatory microenvironments of SCI are discussed, followed by the introduction of microenvironment-regulating biomaterials in terms of their impressive therapeutic effect in attenuation of secondary inflammation and promotion of axon regrowth. With the emphasis on regulating secondary events, the biomaterials for SCI treatment will become promising for clinical applications.
Collapse
Affiliation(s)
- Ziming Li
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, People's Republic of China
| | - Qiaoxuan Wang
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, People's Republic of China
| | - Haijun Hu
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, People's Republic of China
| | - Weiwei Zheng
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, People's Republic of China
| | - Changyou Gao
- MOE Key Laboratory of Macromolecular Synthesis and Functionalization, Department of Polymer Science and Engineering, Zhejiang University, Hangzhou, People's Republic of China.,Dr Li Dak Sum and Yip Yio Chin Center for Stem Cell and Regenerative Medicine, Zhejiang University, Hangzhou, People's Republic of China
| |
Collapse
|
22
|
Boakye M, Ugiliweneza B, Madrigal F, Mesbah S, Ovechkin A, Angeli C, Bloom O, Wecht JW, Ditterline B, Harel NY, Kirshblum S, Forrest G, Wu S, Harkema S, Guest J. Clinical Trial Designs for Neuromodulation in Chronic Spinal Cord Injury Using Epidural Stimulation. Neuromodulation 2021; 24:405-415. [PMID: 33794042 DOI: 10.1111/ner.13381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/11/2021] [Accepted: 02/09/2021] [Indexed: 12/17/2022]
Abstract
STUDY DESIGN This is a narrative review focused on specific challenges related to adequate controls that arise in neuromodulation clinical trials involving perceptible stimulation and physiological effects of stimulation activation. OBJECTIVES 1) To present the strengths and limitations of available clinical trial research designs for the testing of epidural stimulation to improve recovery after spinal cord injury. 2) To describe how studies can control for the placebo effects that arise due to surgical implantation, the physical presence of the battery, generator, control interfaces, and rehabilitative activity aimed to promote use-dependent plasticity. 3) To mitigate Hawthorne effects that may occur in clinical trials with intensive supervised participation, including rehabilitation. MATERIALS AND METHODS Focused literature review of neuromodulation clinical trials with integration to the specific context of epidural stimulation for persons with chronic spinal cord injury. CONCLUSIONS Standard of care control groups fail to control for the multiple effects of knowledge of having undergone surgical procedures, having implanted stimulation systems, and being observed in a clinical trial. The irreducible effects that have been identified as "placebo" require sham controls or comparison groups in which both are implanted with potentially active devices and undergo similar rehabilitative training.
Collapse
Affiliation(s)
- Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Health Management and Systems Sciences, University of Louisville, Louisville, KY, USA
| | - Fabian Madrigal
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Samineh Mesbah
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Alexander Ovechkin
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Claudia Angeli
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Bioengineering, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - Ona Bloom
- Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Molecular Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,Department of Physical Medicine and Rehabilitation, Zucker School of Medicine at Hofstra Northwell, Manhasset, NY, USA.,James J Peters VA Medical Center, Bronx, NY, USA
| | - Jill W Wecht
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Bonnie Ditterline
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA
| | - Noam Y Harel
- James J Peters VA Medical Center, Bronx, NY, USA.,The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NY, USA.,Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA
| | - Gail Forrest
- Human Performance and Engineering Research, Kessler Foundation, West Orange, NJ, USA.,Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Samuel Wu
- Department of Biostatistics, CTSI Data Coordinating Center, University of Florida, Gainesville, FL, USA
| | - Susan Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, USA
| | - James Guest
- Neurological Surgery, and the Miami Project to Cure Paralysis, Miller School of Medicine, Miami, FL, USA
| |
Collapse
|