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Taccola G, Kissane R, Culaclii S, Apicella R, Liu W, Gad P, Ichiyama RM, Chakrabarty S, Edgerton VR. Dynamic electrical stimulation enhances the recruitment of spinal interneurons by corticospinal input. Exp Neurol 2024; 371:114589. [PMID: 37907125 DOI: 10.1016/j.expneurol.2023.114589] [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: 06/30/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023]
Abstract
Highly varying patterns of electrostimulation (Dynamic Stimulation, DS) delivered to the dorsal cord through an epidural array with 18 independent electrodes transiently facilitate corticospinal motor responses, even after spinal injury. To partly unravel how corticospinal input are affected by DS, we introduced a corticospinal platform that allows selective cortical stimulation during the multisite acquisition of cord dorsum potentials (CDPs) and the simultaneous supply of DS. Firstly, the epidural interface was validated by the acquisition of the classical multisite distribution of CDPs and their input-output profile elicited by pulses delivered to peripheral nerves. Apart from increased EMGs, DS selectively increased excitability of the spinal interneurons that first process corticospinal input, without changing the magnitude of commands descending from the motor cortex, suggesting a novel correlation between muscle recruitment and components of cortically-evoked CDPs. Finally, DS increases excitability of post-synaptic spinal interneurons at the stimulation site and their responsiveness to any residual supraspinal control, thus supporting the use of electrical neuromodulation whenever the motor output is jeopardized by a weak volitional input, due to a partial disconnection from supraspinal structures and/or neuronal brain dysfunctions.
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Affiliation(s)
- Giuliano Taccola
- Neuroscience Department, International School for Advanced Studies (SISSA), Bonomea 265, Trieste, Italy; School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK.
| | - Roger Kissane
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK; Department of Musculoskeletal & Ageing Science, University of Liverpool, The William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Stanislav Culaclii
- Department of Bioengineering, University of California, Los Angeles, CA 90095, USA
| | - Rosamaria Apicella
- Neuroscience Department, International School for Advanced Studies (SISSA), Bonomea 265, Trieste, Italy
| | - Wentai Liu
- Department of Bioengineering, University of California, Los Angeles, CA 90095, USA; UCLA California NanoSystems Institute, University of California, Los Angeles, CA, USA
| | - Parag Gad
- SpineX Inc, Los Angeles, CA 90064, USA
| | - Ronaldo M Ichiyama
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - Samit Chakrabarty
- School of Biomedical Sciences, Faculty of Biological Sciences, University of Leeds, Leeds LS2 9JT, UK
| | - V Reggie Edgerton
- Rancho Research Institute, Los Amigos National Rehabilitation Center, Downey, CA 90242, USA; University of Southern California Neurorestoration Center, Keck School of Medicine, Los Angeles, CA 90033; USA; Institut Guttmann, Hospital de Neurorehabilitació, Institut Universitari adscrit a la Universitat Autònoma de Barcelona, Barcelona, Badalona 08916, Spain
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Hoglund BK, Zurn CA, Madden LR, Hoover C, Slopsema JP, Balser D, Parr A, Samadani U, Johnson MD, Netoff TI, Darrow DP. Mapping Spinal Cord Stimulation-Evoked Muscle Responses in Patients With Chronic Spinal Cord Injury. Neuromodulation 2023; 26:1371-1380. [PMID: 36517395 DOI: 10.1016/j.neurom.2022.10.058] [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] [Received: 06/23/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Epidural spinal cord stimulation (eSCS) has shown promise for restoring some volitional motor control after spinal cord injury (SCI). Maximizing therapeutic response requires effective spatial stimulation generated through careful configuration of anodes and cathodes on the eSCS lead. By exploring the way the spatial distribution of low frequency stimulation affects muscle activation patterns, we investigated the spatial specificity of stimulation-evoked responses for targeted muscle groups for restoration after chronic SCI (cSCI) in participants in the Epidural Stimulation After Neurologic Damage (E-STAND) trial. MATERIALS AND METHODS Fifteen participants with Abbreviated Injury Scale A cSCI from the E-STAND study were evaluated with a wide range of bipolar spatial patterns. Surface electromyography captured stimulation-evoked responses from the rectus abdominis (RA), intercostal, paraspinal, iliopsoas, rectus femoris (RF), tibialis anterior (TA), extensor hallucis longus (EHL), and gastrocnemius muscle groups bilaterally. Peak-to-peak amplitudes were analyzed for each pulse across muscles. Stimulation patterns with dipoles parallel (vertical configurations), perpendicular (horizontal configurations), and oblique (diagonal configurations) relative to the rostral-caudal axis were evaluated. RESULTS Cathodic stimulation in the transverse plane indicated ipsilaterally biased activation in RA, intercostal, paraspinal, iliopsoas, RF, TA, EHL, and gastrocnemius muscles (p < 0.05). We found that caudal cathodic stimulation was significantly more activating only in the RF and EHL muscle groups than in the rostral (p < 0.037 and p < 0.006, respectively). Oblique stimulation was found to be more activating in the RA, intercostal, paraspinal, iliopsoas, and TA muscle groups than in the transverse (p < 0.05). CONCLUSIONS Cathodic stimulation provides uniform specificity for targeting laterality. Few muscle groups responded specifically to variation in rostral/caudal stimulation, and oblique stimulation improved stimulation responses when compared with horizontal configurations. These relations may enable tailored targeting of muscle groups, but the surprising amount of variation observed suggests that monitoring these evoked muscle responses will play a key role in this tailoring process. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT03026816.
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Affiliation(s)
| | - Claire A Zurn
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Lauren R Madden
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Caleb Hoover
- Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Julia P Slopsema
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - David Balser
- Department of Rehabilitation Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Ann Parr
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA
| | - Uzma Samadani
- Department of Surgery, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Matthew D Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Theoden I Netoff
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - David P Darrow
- Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA; Division of Neurosurgery, Department of Surgery, Hennepin County Medical Center, Minneapolis, MN, USA.
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Medina R, Ho A, Reddy R, Chen J, Castellanos J. Narrative review of current neuromodulation modalities for spinal cord injury. FRONTIERS IN PAIN RESEARCH 2023; 4:1143405. [PMID: 36969918 PMCID: PMC10033643 DOI: 10.3389/fpain.2023.1143405] [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: 01/13/2023] [Accepted: 02/20/2023] [Indexed: 03/11/2023] Open
Abstract
Neuromodulation is a developing field of medicine that includes a vast array of minimally invasive and non-invasive therapies including transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), vagus nerve stimulation (VNS), peripheral nerve stimulation, and spinal cord stimulation (SCS). Although the current literature surrounding the use of neuromodulation in managing chronic pain is abundant, there is an insufficient amount of evidence specifically regarding neuromodulation in patients with spinal cord injury (SCI). Given the pain and functional deficits that these patients face, that are not amenable to other forms conservative therapy, the purpose of this narrative review is to examine and assess the use of various neuromodulation modalities to manage pain and restore function in the SCI population. Currently, high-frequency spinal cord stimulation (HF-SCS) and burst spinal cord stimulation (B-SCS) have been shown to have the most promising effect in improving pain intensity and frequency. Additionally, dorsal root ganglion stimulation (DRG-S) and TMS have been shown to effectively increase motor responses and improve limb strength. Although these modalities carry the potential to enhance overall functionality and improve a patient's degree of disability, there is a lack of long-term, randomized-controlled trials in the current space. Additional research is warranted to further support the clinical use of these emerging modalities to provide improved pain management, increased level of function, and ultimately an overall better quality of life in the SCI population.
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Affiliation(s)
- Roi Medina
- Department of Physical Medicine and Rehabilitation, Lake Erie College of Osteopathic Medicine-Bradenton, Bradenton, FL, United States
| | - Alison Ho
- Department of Physical Medicine and Rehabilitation, Baylor University Medical Center, Dallas, TX, United States
| | - Rajiv Reddy
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Jeffrey Chen
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
| | - Joel Castellanos
- UC San Diego Health, University of California San Diego, La Jolla, CA, United States
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Balbinot G, Joner Wiest M, Li G, Pakosh M, Cesar Furlan J, Kalsi-Ryan S, Zariffa J. The use of surface EMG in neurorehabilitation following traumatic spinal cord injury: a scoping review. Clin Neurophysiol 2022; 138:61-73. [DOI: 10.1016/j.clinph.2022.02.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/06/2022] [Accepted: 02/27/2022] [Indexed: 11/03/2022]
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Activity-dependent spinal cord neuromodulation rapidly restores trunk and leg motor functions after complete paralysis. Nat Med 2022; 28:260-271. [PMID: 35132264 DOI: 10.1038/s41591-021-01663-5] [Citation(s) in RCA: 164] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 12/16/2021] [Indexed: 12/15/2022]
Abstract
Epidural electrical stimulation (EES) targeting the dorsal roots of lumbosacral segments restores walking in people with spinal cord injury (SCI). However, EES is delivered with multielectrode paddle leads that were originally designed to target the dorsal column of the spinal cord. Here, we hypothesized that an arrangement of electrodes targeting the ensemble of dorsal roots involved in leg and trunk movements would result in superior efficacy, restoring more diverse motor activities after the most severe SCI. To test this hypothesis, we established a computational framework that informed the optimal arrangement of electrodes on a new paddle lead and guided its neurosurgical positioning. We also developed software supporting the rapid configuration of activity-specific stimulation programs that reproduced the natural activation of motor neurons underlying each activity. We tested these neurotechnologies in three individuals with complete sensorimotor paralysis as part of an ongoing clinical trial ( www.clinicaltrials.gov identifier NCT02936453). Within a single day, activity-specific stimulation programs enabled these three individuals to stand, walk, cycle, swim and control trunk movements. Neurorehabilitation mediated sufficient improvement to restore these activities in community settings, opening a realistic path to support everyday mobility with EES in people with SCI.
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Vuka I, Marciuš T, Kovačić D, Šarolić A, Puljak L, Sapunar D. Implantable, Programmable, and Wireless Device for Electrical Stimulation of the Dorsal Root Ganglion in Freely-Moving Rats: A Proof of Concept Study. J Pain Res 2021; 14:3759-3772. [PMID: 34916842 PMCID: PMC8668248 DOI: 10.2147/jpr.s332438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This was a proof of concept study, based on systematic reviews of the efficacy and safety of the dorsal root ganglion (DRG) stimulation. The main objective was to develop an implantable, programmable, and wireless device for electrical stimulation of DRG and a methodology that can be used in translational research, especially to understand the mechanism of neuromodulation and to test new treatment modalities in animal models of pain. Methods We developed and tested a stimulator that uses a battery-powered microelectronic circuit, to generate constant current square biphasic or monophasic pulsed waveform of variable amplitudes and duration. It is controlled by software and an external controller that allows radio frequency communication with the stimulator. The stimulator was implanted in Sprague–Dawley (SD) rats. The lead was positioned at the L5 DRG level, while the stimulator was placed in the skin pocket at the ipsilateral side. Forty-five animals were used and divided into six groups: spinal nerve ligation (SNL), chronic compression injury of the DRG (CCD), SNL + active DRG stimulation, intact control group, group with the implanted sham stimulator, and sham lead. Behavioral testing was performed on the day preceding surgery and three times postoperatively (1st, 3rd, and 7th day). Results In animals with SNL, neurostimulation reduced pain-related behavior, tested with pinprick hyperalgesia, pinprick withdrawal test, and cold test, while the leads per se did not cause DRG compression. The rats well tolerated the stimulator. It did not hinder animal movement, and it enabled the animals to be housed under regular conditions. Conclusion A proof-of-concept experiment with our stimulator verified the usability of the device. The stimulator enables a wide range of research applications from adjusting stimulation parameters for different pain conditions, studying new stimulation methods with different frequencies and waveforms to obtain knowledge about analgesic mechanisms of DRG stimulation.
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Affiliation(s)
- Ivana Vuka
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Tihana Marciuš
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
| | - Damir Kovačić
- Laboratory for Biophysics and Medical Neuroelectronics, University of Split Faculty of Science, Split, Croatia
| | - Antonio Šarolić
- Laboratory for Applied Electromagnetics (EMLab), FESB, University of Split, Split, Croatia
| | - Livia Puljak
- Centre for Evidence-Based Medicine and Health Care, Catholic University of Croatia, Zagreb, Croatia
| | - Damir Sapunar
- Laboratory for Pain Research, University of Split School of Medicine, Split, Croatia
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Soloukey S, Drenthen J, Osterthun R, de Vos CC, De Zeeuw CI, Huygen FJPM, Harhangi BS. How to Identify Responders and Nonresponders to Dorsal Root Ganglion-Stimulation Aimed at Eliciting Motor Responses in Chronic Spinal Cord Injury: Post Hoc Clinical and Neurophysiological Tests in a Case Series of Five Patients. Neuromodulation 2021; 24:719-728. [PMID: 33749941 PMCID: PMC8359838 DOI: 10.1111/ner.13379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 01/11/2021] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Abstract
Objective While integrity of spinal pathways below injury is generally thought to be an important factor in the success‐rate of neuromodulation strategies for spinal cord injury (SCI), it is still unclear how the integrity of these pathways conveying the effects of stimulation should be assessed. In one of our institutional case series of five patients receiving dorsal root ganglion (DRG)‐stimulation for elicitation of immediate motor response in motor complete SCI, only two out of five patients presented as responders, showing immediate muscle activation upon DRG‐stimulation. The current study focuses on post hoc clinical‐neurophysiological tests performed within this patient series to illustrate their use for prediction of spinal pathway integrity, and presumably, responder‐status. Materials and Methods In a series of three nonresponders and two responders (all male, American Spinal Injury Association [ASIA] impairment scale [AIS] A/B), a test‐battery consisting of questionnaires, clinical measurements, as well as a series of neurophysiological measurements was performed less than eight months after participation in the initial study. Results Nonresponders presented with a complete absence of spasticity and absence of leg reflexes. Additionally, nonresponders presented with close to no compound muscle action potentials (CMAPs) or Hofmann(H)‐reflexes. In contrast, both responders presented with clear spasticity, elicitable leg reflexes, CMAPs, H‐reflexes, and sensory nerve action potentials, although not always consistent for all tested muscles. Conclusions Post hoc neurophysiological measurements were limited in clearly separating responders from nonresponders. Clinically, complete absence of spasticity‐related complaints in the nonresponders was a distinguishing factor between responders and nonresponders in this case series, which mimics prior reports of epidural electrical stimulation, potentially illustrating similarities in mechanisms of action between the two techniques. However, the problem remains that explicit use and report of preinclusion clinical‐neurophysiological measurements is missing in SCI literature. Identifying proper ways to assess these criteria might therefore be unnecessarily difficult, especially for nonestablished neuromodulation techniques.
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Affiliation(s)
- Sadaf Soloukey
- Department of Neurosurgery, Erasmus MC, Rotterdam, The Netherlands.,Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands
| | - Judith Drenthen
- Department of Clinical Neurophysiology, Erasmus MC, Rotterdam, The Netherlands
| | - Rutger Osterthun
- Department of Rehabilitation Medicine, Erasmus MC, Rotterdam, The Netherlands.,Spinal Cord Injury Department, Rijndam Rehabilitation Center, Rotterdam, The Netherlands
| | - Cecile C de Vos
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
| | - Chris I De Zeeuw
- Department of Neuroscience, Erasmus MC, Rotterdam, The Netherlands.,Netherlands Institute for Neuroscience, Royal Dutch Academy for Arts and Sciences (KNAW), Amsterdam, The Netherlands
| | - Frank J P M Huygen
- Center for Pain Medicine, Department of Anesthesiology, Erasmus MC, Rotterdam, The Netherlands
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