1
|
Senger JL, Power H, Moore AM. Electrical Stimulation: How It Works and How to Apply It. Hand Clin 2024; 40:409-420. [PMID: 38972685 DOI: 10.1016/j.hcl.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2024]
Abstract
Electrical stimulation is emerging as a perioperative strategy to improve peripheral nerve regeneration and enhance functional recovery. Despite decades of research, new insights into the complex multifaceted mechanisms of electrical stimulation continue to emerge, providing greater understanding of the neurophysiology of nerve regeneration. In this study, we summarize what is known about how electrical stimulation modulates the molecular cascades and cellular responses innate to nerve injury and repair, and the consequential effects on axonal growth and plasticity. Further, we discuss how electrical stimulation is delivered in preclinical and clinical studies and identify knowledge gaps that may provide opportunities for optimization.
Collapse
Affiliation(s)
- Jenna-Lynn Senger
- Division of Plastic Surgery, University of British Columbia, Suite 1788, 1111 W Georgia Street, Vancouver, British Columbia, V6E 4M3, Canada
| | - Hollie Power
- Division of Plastic Surgery, Department of Surgery, University of Alberta, Suite 401, 316 Windermere Road NorthWest, Edmonton, Alberta T6W 2Z8, Canada
| | - Amy M Moore
- Department of Plastic and Reconstructive Surgery, The Ohio State University, 915 Olentangy River Road Suite 2100, Columbus, OH 43212, USA.
| |
Collapse
|
2
|
Trambitas C, Pap T, Niculescu R, Popelea MC, Cotoi OS, Cordoș B, Domnariu HP, Marin A, Feier AM, David C, Vintila C. Biocompatible 3D-Printed Devices With Adipose Stem Cells in the Regenerative Process of Sciatic Nerve Lesions in Rodent Models: An Experimental Study. Cureus 2024; 16:e62412. [PMID: 39011200 PMCID: PMC11248491 DOI: 10.7759/cureus.62412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2024] [Indexed: 07/17/2024] Open
Abstract
INTRODUCTION Peripheral nerve injuries are a significant clinical challenge. The rat sciatic nerve serves as an ideal model for studying nerve regeneration. Extensive research has been conducted to unravel the intricate mechanisms involved in peripheral nerve regeneration, aiming to develop effective therapeutic strategies for nerve injury patients. Research including different types of materials that can be used as nerve guides like synthetic polymers have been investigated for their biocompatibility and molding properties. Among multiple stem cell types, adipose-derived stem cells (ASCs), bone marrow-derived mesenchymal stem cells (BM-MSCs), and induced pluripotent stem cells (iPSCs) have shown neuroprotective and regenerative important properties. METHODS The purposes of our study were to develop a protocol for rat sciatic nerve injury treated with 3D-printed guide and adipose stem cells to investigate nerve regeneration through histologic examination and biomechanical characteristics of muscular tissue. We use 20 (100%) male Wistar rats, measuring between 350 g ± 35 g, who underwent complete transection of the right sciatic nerve, resulting in a 1 cm defect. The group was separated into three subgroups: the first subgroup (n = 8) was treated with a 3D-printed guide with adipose stem cells, the second subgroup (n = 8) was treated with a 3D-printed guide without adipose stem cells, and the third subgroup (n = 4) was the control group. At four, eight, and 12 weeks, we measured with ultrasonography the grade of muscular atrophy. At 12 weeks, we harvested the sciatic nerve and performed a histological examination and mechanical investigation of the tibialis anterior muscle. RESULTS On the examined specimen of the first subgroup, cross-sectioned nerve structures were present, surrounded by a mature fibro-adipose connective tissue, with blood vessels. In the second subgroup, no nerve structure was observed on the examined sections, but in the polymorphic inflammatory infiltrate and control group, no signs of regeneration were found. CONCLUSIONS The present study shows a promising potential when utilizing adipose stem cell-based therapies for promoting peripheral nerve regeneration following large (>1 cm) nerve defects knowing that at this size, regeneration is impossible with known treatments.
Collapse
Affiliation(s)
- Cristian Trambitas
- Plastic and Reconstructive Surgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Timea Pap
- Plastic and Reconstructive Surgery, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Raluca Niculescu
- Pathology and Laboratory Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Maria Catalina Popelea
- Pathology and Laboratory Medicine, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Ovidiu S Cotoi
- Physiopathology, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Bogdan Cordoș
- Center of Experimental and Imaging Studies, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Horatiu-Paul Domnariu
- Plastic and Reconstructive Surgery, University of Oradea, Lucian Blaga University of Sibiu, Oradea, ROU
| | - Andrei Marin
- Plastic and Reconstructive Surgery, Carol Davila University of Medicine and Pharmacy, Bucuresti, ROU
| | - Andrei Marian Feier
- Orthopaedics, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, Targu Mures, ROU
| | - Camelia David
- Plastic and Reconstructive Surgery, Emergency County Hospital Targu Mures, Targu Mures, ROU
| | - Cristian Vintila
- Plastic and Reconstructive Surgery, Emergency County Hospital Targu Mures, Targu Mures, ROU
| |
Collapse
|
3
|
Tian T, Moore AM, Ghareeb PA, Boulis NM, Ward PJ. A Perspective on Electrical Stimulation and Sympathetic Regeneration in Peripheral Nerve Injuries. Neurotrauma Rep 2024; 5:172-180. [PMID: 38463421 PMCID: PMC10924057 DOI: 10.1089/neur.2023.0133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024] Open
Abstract
Peripheral nerve injuries (PNIs) are common and devastating. The current standard of care relies on the slow and inefficient process of nerve regeneration after surgical intervention. Electrical stimulation (ES) has been shown to both experimentally and clinically result in improved regeneration and functional recovery after PNI for motor and sensory neurons; however, its effects on sympathetic regeneration have never been studied. Sympathetic neurons are responsible for a myriad of homeostatic processes that include, but are not limited to, blood pressure, immune response, sweating, and the structural integrity of the neuromuscular junction. Almost one quarter of the axons in the sciatic nerve are from sympathetic neurons, and their importance in bodily homeostasis and the pathogenesis of neuropathic pain should not be underestimated. Therefore, as ES continues to make its way into patient care, it is not only important to understand its impact on all neuron subtypes, but also to ensure that potential adverse effects are minimized. This piece gives an overview of the effects of ES in animals models and in humans while offering a perspective on the potential effects of ES on sympathetic axon regeneration.
Collapse
Affiliation(s)
- Tina Tian
- Medical Scientist Training Program, Emory University, Atlanta, Georgia, USA
- Neuroscience Graduate Program, Laney Graduate School, Emory University, Atlanta, Georgia, USA
- Department of Cell Biology, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Amy M Moore
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Paul A Ghareeb
- Division of Plastic Surgery, Department of Surgery, Emory University, Atlanta, Georgia, USA
| | | | - Patricia J Ward
- Neuroscience Graduate Program, Laney Graduate School, Emory University, Atlanta, Georgia, USA
- Department of Cell Biology, School of Medicine, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
4
|
Gordon T. Brief Electrical Stimulation Promotes Recovery after Surgical Repair of Injured Peripheral Nerves. Int J Mol Sci 2024; 25:665. [PMID: 38203836 PMCID: PMC10779324 DOI: 10.3390/ijms25010665] [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: 10/13/2023] [Revised: 12/07/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Injured peripheral nerves regenerate their axons in contrast to those in the central nervous system. Yet, functional recovery after surgical repair is often disappointing. The basis for poor recovery is progressive deterioration with time and distance of the growth capacity of the neurons that lose their contact with targets (chronic axotomy) and the growth support of the chronically denervated Schwann cells (SC) in the distal nerve stumps. Nonetheless, chronically denervated atrophic muscle retains the capacity for reinnervation. Declining electrical activity of motoneurons accompanies the progressive fall in axotomized neuronal and denervated SC expression of regeneration-associated-genes and declining regenerative success. Reduced motoneuronal activity is due to the withdrawal of synaptic contacts from the soma. Exogenous neurotrophic factors that promote nerve regeneration can replace the endogenous factors whose expression declines with time. But the profuse axonal outgrowth they provoke and the difficulties in their delivery hinder their efficacy. Brief (1 h) low-frequency (20 Hz) electrical stimulation (ES) proximal to the injury site promotes the expression of endogenous growth factors and, in turn, dramatically accelerates axon outgrowth and target reinnervation. The latter ES effect has been demonstrated in both rats and humans. A conditioning ES of intact nerve days prior to nerve injury increases axonal outgrowth and regeneration rate. Thereby, this form of ES is amenable for nerve transfer surgeries and end-to-side neurorrhaphies. However, additional surgery for applying the required electrodes may be a hurdle. ES is applicable in all surgeries with excellent outcomes.
Collapse
Affiliation(s)
- Tessa Gordon
- Division of Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, ON M4G 1X8, Canada
| |
Collapse
|
5
|
Bateman EA, Larocerie-Salgado J, Ross DC, Miller TA, Pripotnev S. Assessment, patient selection, and rehabilitation of nerve transfers. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1267433. [PMID: 38058570 PMCID: PMC10696649 DOI: 10.3389/fresc.2023.1267433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/07/2023] [Indexed: 12/08/2023]
Abstract
Peripheral nerve injuries are common and can have a devastating effect on physical, psychological, and socioeconomic wellbeing. Peripheral nerve transfers have become the standard of care for many types of peripheral nerve injury due to their superior outcomes relative to conventional techniques. As the indications for, and use of, nerve transfers expand, the importance of pre-operative assessment and post-operative optimization increases. There are two principal advantages of nerve transfers: (1) their ability to shorten the time to reinnervation of muscles undergoing denervation because of peripheral nerve injury; and (2) their specificity in ensuring proximal motor and sensory axons are directed towards appropriate motor and sensory targets. Compared to conventional nerve grafting, nerve transfers offer opportunities to reinnervate muscles affected by cervical spinal cord injury and to augment natural reinnervation potential for very proximal injuries. This article provides a narrative review of the current scientific knowledge and clinical understanding of nerve transfers including peripheral nerve injury assessment and pre- and post-operative electrodiagnostic testing, adjuvant therapies, and post-operative rehabilitation for optimizing nerve transfer outcomes.
Collapse
Affiliation(s)
- Emma A. Bateman
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | | | - Douglas C. Ross
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Thomas A. Miller
- Department of Physical Medicine & Rehabilitation, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
- Parkwood Institute, St Joseph’s Health Care London, London, ON, Canada
| | - Stahs Pripotnev
- Roth McFarlane Hand & Upper Limb Centre, St Joseph’s Health Care London, London, ON, Canada
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| |
Collapse
|
6
|
Wariyar SS, Ward PJ. Application of Electrical Stimulation to Enhance Axon Regeneration Following Peripheral Nerve Injury. Bio Protoc 2023; 13:e4833. [PMID: 37817898 PMCID: PMC10560632 DOI: 10.21769/bioprotoc.4833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/06/2023] [Accepted: 07/27/2023] [Indexed: 10/12/2023] Open
Abstract
Enhancing axon regeneration is a major focus of peripheral nerve injury research. Although peripheral axons possess a limited ability to regenerate, their functional recovery is very poor. Various activity-based therapies like exercise, optical stimulation, and electrical stimulation as well as pharmacologic treatments can enhance spontaneous axon regeneration. In this protocol, we use a custom-built cuff to electrically stimulate the whole sciatic nerve for an hour prior to transection and repair. We used a Thy-1-YFP-H mouse to visualize regenerating axon profiles. We compared the regeneration of axons from nerves that were electrically stimulated to nerves that were not stimulated (untreated). Electrically stimulated nerves had longer axon growth than the untreated nerves. We detail how variations of this method can be used to measure acute axon growth.
Collapse
Affiliation(s)
- Supriya S. Wariyar
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, USA
| | - Patricia J. Ward
- Department of Cell Biology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
7
|
Tian T, Harris A, Owyoung J, SiMa H, Ward PJ. Conditioning electrical stimulation fails to enhance sympathetic axon regeneration. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.02.03.527071. [PMID: 36778305 PMCID: PMC9915730 DOI: 10.1101/2023.02.03.527071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral nerve injuries are common, and there is a critical need for the development of novel therapeutics to complement surgical repair. Conditioning electrical stimulation (CES) is a novel variation to the well-studied perioperative electrical stimulation, both of which have displayed success in enhancing the regeneration of motor and sensory axons in an injured peripheral nerve. CES is a clinically attractive alternative not only because of its ability to be performed at the bedside prior to a scheduled nerve repair surgery, but it has also been shown to be superior to perioperative electrical stimulation in the enhancement of motor and sensory regeneration. However, the effects of CES on sympathetic regeneration are unknown. Therefore, we tested the effects of two clinically relevant CES paradigms on sympathetic axon regeneration and distal target reinnervation. Because of the long history of evidence for the enhancement of motor and sensory axons in response to electrical stimulation, we hypothesize that CES will also enhance sympathetic axon regeneration. Our results indicate that the growth of sympathetic axons is acutely inhibited by CES; however, at a longer survival time point post-injury, there is no difference between sham CES and the CES groups. There has been evidence to suggest that the growth of sympathetic axons is inhibited by a conditioning lesion, and that sympathetic axons may respond to electrical stimulation by sprouting rather than elongation. Our data indicate that sympathetic axons may retain some regenerative ability after CES, but no enhancement is exhibited, which may be accounted for by the inability of the current clinically relevant electrical stimulation paradigm to recruit the small-caliber sympathetic axons into activity. Further studies will be needed to optimize electrical stimulation parameters in order to enhance the regeneration of all neuron types.
Collapse
|
8
|
Juckett L, Saffari TM, Ormseth B, Senger JL, Moore AM. The Effect of Electrical Stimulation on Nerve Regeneration Following Peripheral Nerve Injury. Biomolecules 2022; 12:biom12121856. [PMID: 36551285 PMCID: PMC9775635 DOI: 10.3390/biom12121856] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/02/2022] [Accepted: 12/07/2022] [Indexed: 12/15/2022] Open
Abstract
Peripheral nerve injuries (PNI) are common and often result in lifelong disability. The peripheral nervous system has an inherent ability to regenerate following injury, yet complete functional recovery is rare. Despite advances in the diagnosis and repair of PNIs, many patients suffer from chronic pain, and sensory and motor dysfunction. One promising surgical adjunct is the application of intraoperative electrical stimulation (ES) to peripheral nerves. ES acts through second messenger cyclic AMP to augment the intrinsic molecular pathways of regeneration. Decades of animal studies have demonstrated that 20 Hz ES delivered post-surgically accelerates axonal outgrowth and end organ reinnervation. This work has been translated clinically in a series of randomized clinical trials, which suggest that ES can be used as an efficacious therapy to improve patient outcomes following PNIs. The aim of this review is to discuss the cellular physiology and the limitations of regeneration after peripheral nerve injuries. The proposed mechanisms of ES protocols and how they facilitate nerve regeneration depending on timing of administration are outlined. Finally, future directions of research that may provide new perspectives on the optimal delivery of ES following PNI are discussed.
Collapse
|
9
|
Abstract
PURPOSE OF REVIEW To review advances in the diagnostic evaluation and management of traumatic peripheral nerve injuries. RECENT FINDINGS Serial multimodal assessment of peripheral nerve injuries facilitates assessment of spontaneous axonal regeneration and selection of appropriate patients for early surgical intervention. Novel surgical and rehabilitative approaches have been developed to complement established strategies, particularly in the area of nerve grafting, targeted rehabilitation strategies and interventions to promote nerve regeneration. However, several management challenges remain, including incomplete reinnervation, traumatic neuroma development, maladaptive central remodeling and management of fatigue, which compromise functional recovery. SUMMARY Innovative approaches to the assessment and treatment of peripheral nerve injuries hold promise in improving the degree of functional recovery; however, this remains a complex and evolving area.
Collapse
|
10
|
Trueman RP, Ahlawat AS, Phillips JB. A Shock to the (Nervous) System: Bioelectricity Within Peripheral Nerve Tissue Engineering. TISSUE ENGINEERING. PART B, REVIEWS 2022; 28:1137-1150. [PMID: 34806913 DOI: 10.1089/ten.teb.2021.0159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The peripheral nervous system has the remarkable ability to regenerate in response to injury. However, this is only successful over shorter nerve gaps and often provides poor outcomes for patients. Currently, the gold standard of treatment is the surgical intervention of an autograft, whereby patient tissue is harvested and transplanted to bridge the nerve gap. Despite being the gold standard, more than half of patients have dissatisfactory functional recovery after an autograft. Peripheral nerve tissue engineering aims to create biomaterials that can therapeutically surpass the autograft. Current tissue-engineered constructs are designed to deliver a combination of therapeutic benefits to the regenerating nerve, such as supportive cells, alignment, extracellular matrix, soluble factors, immunosuppressants, and other therapies. An emerging therapeutic opportunity in nerve tissue engineering is the use of electrical stimulation (ES) to modify and enhance cell function. ES has been shown to positively affect four key cell types, such as neurons, endothelial cells, macrophages, and Schwann cells, involved in peripheral nerve repair. Changes elicited include faster neurite extension, cellular alignment, and changes in cell phenotype associated with improved regeneration and functional recovery. This review considers the relevant modes of administration and cellular responses that could underpin incorporation of ES into nerve tissue engineering strategies. Impact Statement Tissue engineering is becoming increasingly complex, with multiple therapeutic modalities often included within the final tissue-engineered construct. Electrical stimulation (ES) is emerging as a viable therapeutic intervention to be included within peripheral nerve tissue engineering strategies; however, to date, there have been no review articles that collate the information regarding the effects of ES on key cell within peripheral nerve injury. This review article aims to inform the field on the different therapeutic effects that may be achieved by using ES and how they may become incorporated into existing strategies.
Collapse
Affiliation(s)
- Ryan P Trueman
- Center for Nerve Engineering, Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
| | - Ananya S Ahlawat
- Center for Nerve Engineering, Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
| | - James B Phillips
- Center for Nerve Engineering, Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
- Department of Pharmacology, UCL School of Pharmacy, University College London, London, United Kingdom
| |
Collapse
|
11
|
Senger JLB, Rabey KN, Acton L, Lin YHS, Lingrell S, Chan KM, Webber CA. Recovering the regenerative potential in chronically injured nerves by using conditioning electrical stimulation. J Neurosurg 2022; 136:1442-1454. [PMID: 34653977 DOI: 10.3171/2021.4.jns21398] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Chronically injured nerves pose a significant clinical challenge despite surgical management. There is no clinically feasible perioperative technique to upregulate a proregenerative environment in a chronic nerve injury. Conditioning electrical stimulation (CES) significantly improves sensorimotor recovery following acute nerve injury to the tibial and common fibular nerves. The authors' objective was to determine if CES could foster a proregenerative environment following chronically injured nerve reconstruction. METHODS The tibial nerve of 60 Sprague Dawley rats was cut, and the proximal ends were inserted into the hamstring muscles to prevent spontaneous reinnervation. Eleven weeks postinjury, these chronically injured animals were randomized, and half were treated with CES proximal to the tibial nerve cut site. Three days later, 24 animals were killed to evaluate the effects of CES on the expression of regeneration-associated genes at the cell body (n = 18) and Schwann cell proliferation (n = 6). In the remaining animals, the tibial nerve defect was reconstructed using a 10-mm isograft. Length of nerve regeneration was assessed 3 weeks postgrafting (n = 16), and functional recovery was evaluated weekly between 7 and 19 weeks of regeneration (n = 20). RESULTS Three weeks after nerve isograft surgery, tibial nerves treated with CES prior to grafting had a significantly longer length of nerve regeneration (p < 0.01). Von Frey analysis identified improved sensory recovery among animals treated with CES (p < 0.01). Motor reinnervation, assessed by kinetics, kinematics, and skilled motor tasks, showed significant recovery (p < 0.05 to p < 0.001). These findings were supported by immunohistochemical quantification of motor endplate reinnervation (p < 0.05). Mechanisms to support the role of CES in reinvigorating the regenerative response were assessed, and it was demonstrated that CES increased the proliferation of Schwann cells in chronically injured nerves (p < 0.05). Furthermore, CES upregulated regeneration-associated gene expression to increase growth-associated protein-43 (GAP-43), phosphorylated cAMP response element binding protein (pCREB) at the neuronal cell bodies, and upregulated glial fibrillary acidic protein expression in the surrounding satellite glial cells (p < 0.05 to p < 0.001). CONCLUSIONS Regeneration following chronic axotomy is impaired due to downregulation of the proregenerative environment generated following nerve injury. CES delivered to a chronically injured nerve influences the cell body and the nerve to re-upregulate an environment that accelerates axon regeneration, resulting in significant improvements in sensory and motor functional recovery. Percutaneous CES may be a preoperative strategy to significantly improve outcomes for patients undergoing delayed nerve reconstruction.
Collapse
Affiliation(s)
- Jenna-Lynn B Senger
- 1Division of Plastic Surgery, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - Karyne N Rabey
- 2Division of Anatomy, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
- 4Department of Anthropology, Faculty of Science, University of Alberta, Edmonton, Alberta, Canada
| | - Leah Acton
- 2Division of Anatomy, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - Ying-Ho S Lin
- 2Division of Anatomy, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - Susanne Lingrell
- 2Division of Anatomy, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| | - K Ming Chan
- 3Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta; and
| | - Christine A Webber
- 2Division of Anatomy, Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta
| |
Collapse
|
12
|
Role of Electrical Stimulation in Peripheral Nerve Regeneration: A Systematic Review. Plast Reconstr Surg Glob Open 2022; 10:e4115. [PMID: 35317464 PMCID: PMC8932473 DOI: 10.1097/gox.0000000000004115] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 12/14/2021] [Indexed: 01/17/2023]
Abstract
Functional recovery after peripheral nerve injury is often suboptimal despite the intrinsic permissive growth environment of the peripheral nervous system. The objective of this systematic review is to explore the use of electrical stimulation (ES) for peripheral nerve regeneration.
Collapse
|
13
|
Vaginal Electrical Stimulation for Postpartum Neuromuscular Recovery: A Randomized Clinical Trial. Female Pelvic Med Reconstr Surg 2021; 27:659-666. [PMID: 34608032 DOI: 10.1097/spv.0000000000001037] [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
OBJECTIVE The aim of this study was to compare 3-month postpartum anal incontinence symptoms in women who sustain obstetric anal sphincter injuries and begin immediate vaginal electrical stimulation versus sham therapy. METHODS In this double-blind randomized controlled trial, women who sustained obstetric anal sphincter injuries were randomized to receive self-administered vaginal electrical stimulation using a commercial device or sham therapy with an identical device. Anal incontinence symptom severity was assessed at 1 week (baseline) and again at 13 weeks postpartum using the Fecal Incontinence Severity Index. The primary outcome was anal incontinence symptom severity measured by the total Fecal Incontinence Severity Index score at 13 weeks postpartum. RESULTS Between February 2016 and September 2018, 48 women completed a 13-week follow-up. At 13 weeks postpartum, median Fecal Incontinence Severity Index scores were higher (more severe) in the vaginal electrical stimulation group (12; interquartile range, 0-23) than in the sham group (4; interquartile range, 0-10) (P = 0.04). Unlike the vaginal electrical stimulation group, the improvement in Fecal Incontinence Severity Index scores in the sham group (vaginal electrical stimulation: 12 [interquartile range, 8-22] to 12 [interquartile range, 0-23] [P = 0.12] vs sham: 12 [interquartile range, 6-18] to 4.0 [interquartile range, 0-11] [P < 0.001]) met the threshold for clinical significance based on the minimum important difference of the Fecal Incontinence Severity Index. CONCLUSION At 13 weeks postpartum, women who underwent postpartum vaginal electrical stimulation reported more anal incontinence symptoms compared with those receiving sham therapy. Vaginal electrical stimulation after obstetric anal sphincter injury was not beneficial in reducing anal incontinence symptoms and may impede recovery.
Collapse
|
14
|
Guo H, D'Andrea D, Zhao J, Xu Y, Qiao Z, Janes LE, Murthy NK, Li R, Xie Z, Song Z, Meda R, Koo J, Bai W, Choi YS, Jordan SW, Huang Y, Franz CK, Rogers JA. Advanced Materials in Wireless, Implantable Electrical Stimulators That Offer Rapid Rates of Bioresorption for Peripheral Axon Regeneration. ADVANCED FUNCTIONAL MATERIALS 2021; 31:2102724. [PMID: 36189172 PMCID: PMC9521812 DOI: 10.1002/adfm.202102724] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 06/01/2023]
Abstract
Injured peripheral nerves typically exhibit unsatisfactory and incomplete functional outcomes, and there are no clinically approved therapies for improving regeneration. Post-operative electrical stimulation (ES) increases axon regrowth, but practical challenges from the cost of extended operating room time to the risks and pitfalls associated with transcutaneous wire placement have prevented broad clinical adoption. This study presents a possible solution in the form of advanced bioresorbable materials for thin, flexible, wireless implant that provides precisely controlled ES of the injured nerve for a brief time in the immediate post-operative period. Afterward, rapid, complete and safe modes of bioresorption naturally and quickly eliminate all of the constituent materials in their entirety, without the need for surgical extraction. The unusually high rate of bioresorption follows from the use of a unique, bilayer enclosure that combines two distinct formulations of a biocompatible form of polyanhydride as an encapsulating structure, to accelerate the resorption of active components and confine fragments until complete resorption. Results from mouse models of tibial nerve transection with re-anastomosis indicate that this system offers levels of performance and efficacy that match those of conventional wired stimulators, but without the need to extend the operative period or to extract the device hardware.
Collapse
Affiliation(s)
- Hexia Guo
- Department of Materials Science and Engineering, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Dom D'Andrea
- Laboratory of Regenerative Rehabilitation, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
| | - Jie Zhao
- Department of Materials Science and Engineering, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- Department of Materials Science, Fudan University, Shanghai, 200433, China
| | - Yue Xu
- Department of Biomedical Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Zheng Qiao
- Department of Materials Science and Engineering, Northwestern University, Evanston, IL 60208, USA
| | - Lindsay E Janes
- Department of Physical Medicine and Rehabilitation, Neurological Surgery, Division of Plastic and Reconstructive Surgery, Northwestern University, Chicago, IL 60611, USA
| | - Nikhil K Murthy
- Laboratory of Regenerative Rehabilitation, Shirley Ryan AbilityLab, Department of Neurological Surgery, Northwestern University, Chicago, IL 60611, USA
| | - Rui Li
- State Key Laboratory of Structural Analysis for Industrial Equipment, Department of Engineering Mechanics, International Research Center for Computational Mechanics, Dalian University of Technology, Dalian 116024, China
| | - Zhaoqian Xie
- State Key Laboratory of Structural Analysis for Industrial Equipment, Department of Engineering Mechanics, International Research Center for Computational Mechanics, Dalian University of Technology, Dalian 116024, China
| | - Zhen Song
- State Key Laboratory of Structural Analysis for Industrial Equipment, Department of Engineering Mechanics, International Research Center for Computational Mechanics, Dalian University of Technology, Dalian 116024, China
| | - Rohan Meda
- Laboratory of Regenerative Rehabilitation, Shirley Ryan AbilityLab, Chicago, IL 60611, USA
| | - Jahyun Koo
- Department of Materials Science and Engineering, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
- School of Biomedical Engineering, Interdisciplinary Program in precision Public Health, Korea University, Seoul 02841, Republic of Korea
| | - Wubin Bai
- Department of Materials Science and Engineering, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Yeon Sik Choi
- Department of Materials Science and Engineering, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Sumanas W Jordan
- Biologics, Shirley Ryan AbilityLab, Division of Plastic and Reconstructive Surgery, Northwestern University, Chicago, IL 60611, USA
| | - Yonggang Huang
- Department of Civil and Environmental Engineering, Mechanical Engineering, Materials Science and Engineering, Center for Bio-integrated Electronics, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| | - Colin K Franz
- Laboratory of Regenerative Rehabilitation, Shirley Ryan AbilityLab, Department of Physical Medicine and Rehabilitation, The Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - John A Rogers
- Department of Materials Science and Engineering, Biomedical Engineering, Neurological Surgery, Chemistry, Mechanical Engineering, Electrical and Computer Engineering, Center for Bio-integrated Electronics, Querrey Simpson Institute for Bioelectronics, Northwestern University, Evanston, IL 60208, USA
| |
Collapse
|
15
|
Application of electrical stimulation for peripheral nerve regeneration: Stimulation parameters and future horizons. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101117] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
|
16
|
Nadeau JR, Arnold BM, Johnston JM, Muir GD, Verge VMK. Acute intermittent hypoxia enhances regeneration of surgically repaired peripheral nerves in a manner akin to electrical stimulation. Exp Neurol 2021; 341:113671. [PMID: 33684407 DOI: 10.1016/j.expneurol.2021.113671] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 12/12/2022]
Abstract
The intrinsic repair response of injured peripheral neurons is enhanced by brief electrical stimulation (ES) at time of surgical repair, resulting in improved regeneration in rodents and humans. However, ES is invasive. Acute intermittent hypoxia (AIH) - breathing alternate cycles of regular air and air with ~50% normal oxygen levels (11% O2), considered mild hypoxia, is an emerging, promising non-invasive therapy that promotes motor function in spinal cord injured rats and humans. AIH can increase neural activity and under moderately severe hypoxic conditions improves repair of peripherally crushed nerves in mice. Thus, we posited an AIH paradigm similar to that used clinically for spinal cord injury, will improve surgically repaired peripheral nerves akin to ES, including an impact on regeneration-associated gene (RAG) expression-a predictor of growth states. Alterations in early RAG expression were examined in adult male Lewis rats that underwent tibial nerve coaptation repair with either 2 days AIH or normoxia control treatment begun on day 2 post-repair, or 1 h ES treatment (20 Hz) at time of repair. Three days post-repair, AIH or ES treatments effected significant and parallel elevated RAG expression relative to normoxia control at the level of injured sensory and motor neuron cell bodies and proximal axon front. These parallel impacts on RAG expression were coupled with significant improvements in later indices of regeneration, namely enhanced myelination and increased numbers of newly myelinated fibers detected 20 mm distal to the tibial nerve repair site or sensory and motor neurons retrogradely labeled 28 mm distal to the repair site, both at 25 days post nerve repair; and improved return of toe spread function 5-10 weeks post-repair. Collectively, AIH mirrors many beneficial effects of ES on peripheral nerve repair outcomes. This highlights its potential for clinical translation as a non-invasive means to effect improved regeneration of injured peripheral nerves.
Collapse
Affiliation(s)
- J R Nadeau
- Department of Anatomy, Physiology and Pharmacology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; Biomedical Sciences, WCVM, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK S7N 5B4, Canada; Cameco MS Neuroscience Research Centre, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada
| | - B M Arnold
- Biomedical Sciences, WCVM, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK S7N 5B4, Canada; Cameco MS Neuroscience Research Centre, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada
| | - J M Johnston
- Department of Anatomy, Physiology and Pharmacology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; Cameco MS Neuroscience Research Centre, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada
| | - G D Muir
- Biomedical Sciences, WCVM, University of Saskatchewan, 52 Campus Drive, Saskatoon, SK S7N 5B4, Canada; Cameco MS Neuroscience Research Centre, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada
| | - V M K Verge
- Department of Anatomy, Physiology and Pharmacology, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada; Cameco MS Neuroscience Research Centre, University of Saskatchewan, Saskatoon, SK S7K 0M7, Canada.
| |
Collapse
|
17
|
Long Q, Wu B, Yang Y, Wang S, Shen Y, Bao Q, Xu F. Nerve guidance conduit promoted peripheral nerve regeneration in rats. Artif Organs 2021; 45:616-624. [PMID: 33270261 DOI: 10.1111/aor.13881] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 11/19/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022]
Abstract
Nerve growth factor (NGF) is important for peripheral nerve regeneration. However, its short half-life and rapid diffusion in body fluids limit its clinical efficacy. Collagen has favorable biocompatibility and biodegradability, and weak immunogenicity. Because it possesses an NGF binding domain, we cross-linked heparin to collagen tubes to construct nerve guidance conduits for delivering NGF. The conduits were implanted to bridge a facial nerve defect in rats. Histological and functional analyses were performed to assess the effect of the nerve guidance conduit on facial nerve regeneration. Heparin enhanced the binding of NGF to collagen while retaining its bioactivity. Also, the nerve guidance conduit significantly promoted axonal growth and Schwan cell proliferation at 12 weeks after surgery. The nerve regeneration and functional recovery outcomes using the nerve guidance conduit were similar to those of autologous nerve grafting. Therefore, the nerve guidance conduit may promote safer nerve regeneration.
Collapse
Affiliation(s)
- Qingshan Long
- Department of Neurosurgery, Huizhou Third People's Hospital, Guangzhou Medical University, Huizhou, China
| | - Bingshan Wu
- Department of Neurosurgery, First Affiliated Hospital of Anhui Medical University, Hefei City, China
| | - Yu Yang
- Department of Psychiatry, Zigong Mental Health Center, Zigong City, China
| | - Shanhong Wang
- Department of Psychiatry, Zigong Mental Health Center, Zigong City, China
| | - Yiwen Shen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Qinghua Bao
- Department of Neurosurgery, Affiliated Aoyang Hospital of Jiangsu University, Zhangjiagang, China
| | - Feng Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| |
Collapse
|
18
|
Gordon T. Peripheral Nerve Regeneration and Muscle Reinnervation. Int J Mol Sci 2020; 21:ijms21228652. [PMID: 33212795 PMCID: PMC7697710 DOI: 10.3390/ijms21228652] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/24/2022] Open
Abstract
Injured peripheral nerves but not central nerves have the capacity to regenerate and reinnervate their target organs. After the two most severe peripheral nerve injuries of six types, crush and transection injuries, nerve fibers distal to the injury site undergo Wallerian degeneration. The denervated Schwann cells (SCs) proliferate, elongate and line the endoneurial tubes to guide and support regenerating axons. The axons emerge from the stump of the viable nerve attached to the neuronal soma. The SCs downregulate myelin-associated genes and concurrently, upregulate growth-associated genes that include neurotrophic factors as do the injured neurons. However, the gene expression is transient and progressively fails to support axon regeneration within the SC-containing endoneurial tubes. Moreover, despite some preference of regenerating motor and sensory axons to “find” their appropriate pathways, the axons fail to enter their original endoneurial tubes and to reinnervate original target organs, obstacles to functional recovery that confront nerve surgeons. Several surgical manipulations in clinical use, including nerve and tendon transfers, the potential for brief low-frequency electrical stimulation proximal to nerve repair, and local FK506 application to accelerate axon outgrowth, are encouraging as is the continuing research to elucidate the molecular basis of nerve regeneration.
Collapse
Affiliation(s)
- Tessa Gordon
- Department of Surgery, University of Toronto, Division of Plastic Reconstructive Surgery, 06.9706 Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
19
|
Senger JLB, Rabey KN, Morhart MJ, Chan KM, Webber CA. Conditioning Electrical Stimulation Accelerates Regeneration in Nerve Transfers. Ann Neurol 2020; 88:363-374. [PMID: 32447758 DOI: 10.1002/ana.25796] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 05/21/2020] [Accepted: 05/21/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Compared to the upper limb, lower limb distal nerve transfer (DNT) outcomes are poor, likely due to the longer length of regeneration required. DNT surgery to treat foot drop entails rerouting a tibial nerve branch to the denervated common fibular nerve stump to reinnervate the tibialis anterior muscle for ankle dorsiflexion. Conditioning electrical stimulation (CES) prior to nerve repair surgery accelerates nerve regeneration and promotes sensorimotor recovery. We hypothesize that CES prior to DNT will promote nerve regeneration to restore ankle dorsiflexion. METHODS One week following common fibular nerve crush, CES was delivered to the tibial nerve in half the animals, and at 2 weeks, all animals received a DNT. To investigate the effects of CES on nerve regeneration, a series of kinetic, kinematic, skilled locomotion, electrophysiologic, and immunohistochemical outcomes were assessed. The effects of CES on the nerve were investigated. RESULTS CES-treated animals had significantly accelerated nerve regeneration (p < 0.001), increased walking speed, and improved skilled locomotion. The injured limb had greater vertical peak forces, with improved duty factor, near-complete recovery of braking, propulsive forces, and dorsiflexion (p < 0.01). Reinnervation of the tibialis anterior muscle was confirmed with nerve conduction studies and immunohistochemical analysis of the neuromuscular junction. Immunohistochemistry demonstrated that CES does not induce Wallerian degeneration, nor does it cause macrophage infiltration of the distal tibial nerve. INTERPRETATION Tibial nerve CES prior to DNT significantly improved functional recovery of the common fibular nerve and its muscle targets without inducing injury to the donor nerve. ANN NEUROL 2020;88:363-374.
Collapse
Affiliation(s)
- Jenna-Lynn B Senger
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Karyne N Rabey
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Michael J Morhart
- Division of Plastic and Reconstructive Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - K Ming Chan
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|