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Comino-Suárez N, Moreno JC, Megía-García Á, Del-Ama AJ, Serrano-Muñoz D, Avendaño-Coy J, Gil-Agudo Á, Alcobendas-Maestro M, López-López E, Gómez-Soriano J. Transcutaneous spinal cord stimulation combined with robotic-assisted body weight-supported treadmill training enhances motor score and gait recovery in incomplete spinal cord injury: a double-blind randomized controlled clinical trial. J Neuroeng Rehabil 2025; 22:15. [PMID: 39885542 DOI: 10.1186/s12984-025-01545-8] [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: 05/06/2024] [Accepted: 01/07/2025] [Indexed: 02/01/2025] Open
Abstract
BACKGROUND Although transcutaneous spinal cord stimulation (tSCS) has been suggested as a safe and feasible intervention for gait rehabilitation, no studies have determined its effectiveness compared to sham stimulation. OBJECTIVE To determine the effectiveness of tSCS combined with robotic-assisted gait training (RAGT) on lower limb muscle strength and walking function in incomplete spinal cord injury (iSCI) participants. METHODS A randomized, double-blind, sham-controlled clinical trial was conducted. Twenty-seven subacute iSCI participants were randomly allocated to tSCS or sham-tSCS group. All subjects conducted a standard Lokomat walking training program of 40 sessions (5 familiarization sessions, followed by 20 sessions combined with active or sham tSCS, and finally the last 15 sessions with standard Lokomat). Primary outcomes were the lower extremity motor score (LEMS) and dynamometry. Secondary outcomes included the 10-Meter Walk Test (10MWT), the Timed Up and Go test (TUG), the 6-Minute Walk test (6MWT), the Spinal Cord Independence Measure III (SCIM III) and the Walking Index for Spinal Cord Injury II (WISCI-II). Motor evoked potential (MEP) induced by transcranial magnetic stimulation (TMS) were also assessed for lower limb muscles. Assessments were performed before and after tSCS intervention and after 3-weeks follow-up. RESULTS Although no significant differences between groups were detected after the intervention, the tSCS group showed greater effects than the sham-tSCS group for LEMS (3.4 points; p = 0.033), 10MWT (37.5 s; p = 0.030), TUG (47.7 s; p = 0.009), and WISCI-II (3.4 points; p = 0.023) at the 1-month follow-up compared to baseline. Furthermore, the percentage of subjects who were able to walk 10 m at the follow-up was greater in the tSCS group (85.7%) compared to the sham group (43.1%; p = 0.029). Finally, a significant difference (p = 0.049) was observed in the comparison of the effects in the amplitude of the rectus femoris MEPs of tSCS group (- 0.97 mV) and the sham group (- 3.39 mV) at follow-up. CONCLUSIONS The outcomes of this study suggest that the combination of standard Lokomat training with tSCS for 20 sessions was effective for LEMS and gait recovery in subacute iSCI participants after 1 month of follow-up. Trial registration ClinicalTrials.gov (NCT05210166).
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Affiliation(s)
- Natalia Comino-Suárez
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing of Toledo, Universidad de Castilla-La Mancha, Toledo, Spain
- Department of Physical Therapy, Faculty of Health Sciences, Universidad Alfonso X El Sabio, Madrid, Spain
| | - Juan C Moreno
- BioRobotics Group, Center for Automation and Robotics, CSIC-UPM, Spanish National Research Council, Ctra. Campo Real Km 0,2., 28500, Arganda del Rey, Madrid, Spain.
- Unit of Neurorehabilitation, Biomechanics and Sensorimotor Function (HNP-SESCAM), Associated Unit of R&D&I to the CSIC, Toledo, Spain.
| | - Álvaro Megía-García
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing of Toledo, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Antonio J Del-Ama
- Bioengineering Systems and Technologies Research Group, School of Science and Technology, Rey Juan Carlos University, Móstoles, Madrid, Spain
| | - Diego Serrano-Muñoz
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing of Toledo, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Juan Avendaño-Coy
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing of Toledo, Universidad de Castilla-La Mancha, Toledo, Spain
| | - Ángel Gil-Agudo
- Unit of Neurorehabilitation, Biomechanics and Sensorimotor Function (HNP-SESCAM), Associated Unit of R&D&I to the CSIC, Toledo, Spain
- Biomechanics and Technical Aids Unit, National Hospital for Paraplegics, Toledo, Spain
| | - Mónica Alcobendas-Maestro
- Department of Physical Medicine and Rehabilitation, National Hospital for Paraplegics, Toledo, Spain
| | - Esther López-López
- Department of Physical Therapy, National Hospital for Paraplegics, Toledo, Spain
| | - Julio Gómez-Soriano
- Toledo Physiotherapy Research Group (GIFTO), Faculty of Physiotherapy and Nursing of Toledo, Universidad de Castilla-La Mancha, Toledo, Spain
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Smith AC, Morey C, Thornton WA, Connor JR, Pfyffer D, Weber Ii KA, Will K, Tefertiller C. Responsiveness to transcutaneous spinal stimulation for upper extremity recovery following spinal cord injury: A case series exploration of midsagittal tissue bridges. J Spinal Cord Med 2025:1-7. [PMID: 39819187 DOI: 10.1080/10790268.2024.2448046] [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: 01/19/2025] Open
Abstract
CONTEXT Transcutaneous spinal stimulation (TSS), applied to the cervical spine, is able to improve voluntary upper extremity strength and function in individuals with cervical spinal cord injury (SCI). While most respond and improve in the presence of TSS, others do not respond as favorably. Midsagittal tissue bridges, adjacent to the lesion, can be observed and measured using T2-weighted magnetic resonance imaging (MRI), and both ventral and dorsal tissue bridges are associated with recovery following SCI. Tissue bridges may also be important for responding to neuromodulation such as TSS. The purpose of this case series was to explore potential relationships between the presence of tissue bridges and responsiveness to TSS for recovery of upper extremity strength and function in research participants with cervical-level SCI. METHODS This study involved six research participants who completed a clinical trial of rehabilitation paired with TSS to improve upper extremity strength and function. Ventral and dorsal midsagittal tissue bridges were quantified using T2-weighted MRI. RESULTS Three participants classified as both strength and function responders showed presence of ventral tissue bridges, while the three strength-only responders did not. The same was found for dorsal tissue bridges, except for one strength-only responder that had a dorsal tissue bridge. CONCLUSIONS The findings of this case series shed light onto the potential importance of midsagittal tissue bridges - a proxy for spared sensorimotor tracts - for responsiveness to TSS for upper extremity recovery following SCI.
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Affiliation(s)
- Andrew C Smith
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | - Wesley A Thornton
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA
- Craig Hospital, Englewood, Colorado, USA
| | - Jordan R Connor
- Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine, Aurora, Colorado, USA
- Craig Hospital, Englewood, Colorado, USA
| | - Dario Pfyffer
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
| | - Kenneth A Weber Ii
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California, USA
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Hodgkiss DD, Balthazaar SJT, Welch JF, Wadley AJ, Cox PA, Lucas RAI, Veldhuijzen van Zanten JJCS, Chiou SY, Lucas SJE, Nightingale TE. Short- and long-term effects of transcutaneous spinal cord stimulation on autonomic cardiovascular control and arm-crank exercise capacity in individuals with a spinal cord injury (STIMEX-SCI): study protocol. BMJ Open 2025; 15:e089756. [PMID: 39819908 PMCID: PMC11751795 DOI: 10.1136/bmjopen-2024-089756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 12/12/2024] [Indexed: 01/19/2025] Open
Abstract
INTRODUCTION Individuals with higher neurological levels of spinal cord injury (SCI) at or above the sixth thoracic segment (≥T6), exhibit impaired resting cardiovascular control and responses during upper-body exercise. Over time, impaired cardiovascular control predisposes individuals to lower cardiorespiratory fitness and thus a greater risk for cardiovascular disease and mortality. Non-invasive transcutaneous spinal cord stimulation (TSCS) has been shown to modulate cardiovascular responses at rest in individuals with SCI, yet its effectiveness to enhance exercise performance acutely, or promote superior physiological adaptations to exercise following an intervention, in an adequately powered cohort is unknown. Therefore, this study aims to explore the efficacy of acute TSCS for restoring autonomic function at rest and during arm-crank exercise to exhaustion (AIM 1) and investigate its longer-term impact on cardiorespiratory fitness and its concomitant benefits on cardiometabolic health and health-related quality of life (HRQoL) outcomes following an 8-week exercise intervention (AIM 2). METHODS AND ANALYSIS Sixteen individuals aged ≥16 years with a chronic, motor-complete SCI between the fifth cervical and sixth thoracic segments will undergo a baseline TSCS mapping session followed by an autonomic nervous system (ANS) stress test battery, with and without cardiovascular-optimised TSCS (CV-TSCS). Participants will then perform acute, single-session arm-crank exercise (ACE) trials to exhaustion with CV-TSCS or sham TSCS (SHAM-TSCS) in a randomised order. Twelve healthy, age- and sex-matched non-injured control participants will be recruited and will undergo the same ANS tests and exercise trials but without TSCS. Thereafter, the SCI cohort will be randomly assigned to an experimental (CV-TSCS+ACE) or control (SHAM-TSCS+ACE) group. All participants will perform 48 min of ACE twice per week (at workloads corresponding to 73-79% peak oxygen uptake), over a period of 8 weeks, either with (CV-TSCS) or without (SHAM-TSCS) cardiovascular-optimised stimulation. The primary outcomes are time to exhaustion (AIM 1) and cardiorespiratory fitness (AIM 2). Secondary outcomes for AIM 1 include arterial blood pressure, respiratory function, cerebral blood velocity, skeletal muscle tissue oxygenation, along with concentrations of catecholamines, brain-derived neurotrophic factor and immune cell dynamics via venous blood sampling pre, post and 90 min post-exercise. Secondary outcomes for AIM 2 include cardiometabolic health biomarkers, cardiac function, arterial stiffness, 24-hour blood pressure lability, energy expenditure, respiratory function, neural drive to respiratory muscles, seated balance and HRQoL (eg, bowel, bladder and sexual function). Outcome measures will be assessed at baseline, pre-intervention, post-intervention and after a 6-week follow-up period (HRQoL questionnaires only). ETHICS AND DISSEMINATION Ethical approval has been obtained from the Wales Research Ethics Committee 7 (23/WA/0284; 03/11/2024). The recruitment process began in February 2024, with the first enrolment in July 2024. Recruitment is expected to be completed by January 2026. The results will be presented at international SCI and sport-medicine conferences and will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN17856698.
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Affiliation(s)
- Daniel D Hodgkiss
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Shane J T Balthazaar
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- International Collaboration On Repair Discoveries, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Joseph F Welch
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Alex J Wadley
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Phoebe A Cox
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Rebekah A I Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Jet J C S Veldhuijzen van Zanten
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK
| | - Shin-Yi Chiou
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Samuel J E Lucas
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- Centre for Human Brain Health, University of Birmingham, Birmingham, UK
| | - Tom E Nightingale
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
- International Collaboration On Repair Discoveries, The University of British Columbia, Vancouver, British Columbia, Canada
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Gelenitis K, Santamaria A, Pradarelli J, Rieger M, Inanici F, Tefertiller C, Field-Fote E, Guest J, Suggitt J, Turner A, D'Amico JM, Moritz C. Non-invasive Transcutaneous Spinal Cord Stimulation Programming Recommendations for the Treatment of Upper Extremity Impairment in Tetraplegia. Neuromodulation 2025; 28:162-173. [PMID: 38958629 DOI: 10.1016/j.neurom.2024.05.005] [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: 02/05/2024] [Revised: 04/30/2024] [Accepted: 05/18/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVES This study analyzes the stimulation parameters implemented during two successful trials that used non-invasive transcutaneous spinal cord stimulation (tSCS) to effectively improve upper extremity function after chronic spinal cord injury (SCI). It proposes a framework to guide stimulation programming decisions for the successful translation of these techniques into the clinic. MATERIALS AND METHODS Programming data from 60 participants who completed the Up-LIFT trial and from 17 participants who subsequently completed the LIFT Home trial were analyzed. All observations of stimulation amplitudes, frequencies, waveforms, and electrode configurations were examined. The incidence of adverse events and relatedness to stimulation parameters is reported. A comparison of parameter usage across the American Spinal Injury Association Impairment Scale (AIS) subgroups was conducted to evaluate stimulation strategies across participants with varying degrees of sensorimotor preservation. RESULTS Active (cathodal) electrodes were typically placed between the C3/C4 and C6/C7 spinous processes. Most sessions featured return (anodal) electrodes positioned bilaterally over the anterior superior iliac spine, although clavicular placement was frequently used by 12 participants. Stimulation was delivered with a 10-kHz carrier frequency and typically a 30-Hz burst frequency. Biphasic waveforms were used in 83% of sessions. Average stimulation amplitudes were higher for biphasic waveforms. The AIS B subgroup required significantly higher amplitudes than did the AIS C and D subgroups. Device-related adverse events were infrequent, and not correlated with specific waveforms or amplitudes. Within the home setting, participants maintained their current amplitudes within 1% of the preset values. The suggested stimulation programming framework dictates the following hierarchical order of parameter adjustments: current amplitude, waveform type, active/return electrode positioning, and burst frequency, guided by clinical observations as required. CONCLUSIONS This analysis summarizes effective stimulation parameters from the trials and provides a decision-making framework for clinical implementation of tSCS for upper extremity functional restoration after SCI. The parameters are aligned with existing literature and proved safe and well tolerated by participants.
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Affiliation(s)
| | | | | | | | - Fatma Inanici
- Departments of Rehabilitation Medicine, Electrical & Computer Engineering, Center for Neurotechnology, University of Washington. Seattle, WA, USA
| | | | - Edelle Field-Fote
- Shepherd Center, Crawford Research Institute, Emory University School of Medicine, Department of Rehabilitation Medicine, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
| | - James Guest
- Neurological Surgery and the Miami Project to Cure Paralysis, Miller School of Medicine, University of Miami, Miami, FL, USA
| | | | | | - Jessica M D'Amico
- ONWARD Medical, Lausanne, Switzerland; Glenrose Rehabilitation Hospital, Alberta Health Services. Edmonton, Canada; Department of Medicine, University of Alberta. Edmonton, Canada
| | - Chet Moritz
- Departments of Rehabilitation Medicine, Electrical & Computer Engineering, Center for Neurotechnology, University of Washington. Seattle, WA, USA; Department of Physiology & Biophysics, University of Washington. Seattle, WA, USA.
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Sharma P, Rampersaud H, Shah PK. Repeated epidural stimulation modulates cervical spinal cord excitability in healthy adult rats. Exp Brain Res 2024; 243:22. [PMID: 39665849 DOI: 10.1007/s00221-024-06965-x] [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: 06/06/2024] [Accepted: 10/04/2024] [Indexed: 12/13/2024]
Abstract
Spinal evoked motor responses (SEMR) are utilized in longitudinal pre-clinical and human studies to reflect the in-vivo physiological changes in neural networks secondary to a spinal cord injury (SCI) or neuro-rehabilitative treatments utilizing epidural stimulation (ES). However, it remains unknown whether the repeated ES exposure during SEMR testing itself modulates spinal cord physiology and accompanying SEMR characteristics. To answer this, ES was delivered to the cervical spinal cord using standard stimulation paradigms during multiple SEMR data acquisition sessions (~ 17 h spanning across 100 days) in ten healthy adult rats. Cervical SEMR at rest and forelimb muscle activity during reaching and grasping task were collected before and after 100 days. We noted a persistent increase in SEMR activity relative to baseline, with prominent changes in the mono and poly-synaptic components of SEMR. The findings indicate increased spinal cord excitability. Increased spinal cord excitability translated into increased forelimb muscle activation during the reaching and grasping task. For the majority of SEMR and muscle activity increase, effect size was large or very large. Cervical SEMR are amenable to modulation by routine ES testing protocols, with prominent changes in the mono and poly-synaptic components of SEMR. Since repeated stimulation during multiple testing alone increases cord excitability, we recommend (1) SEMR may be used with caution to infer the physiological status of the spinal circuitry (2) utilizing appropriate control groups and motor behavioral correlates for meaningful functional interpretation in longitudinal neuromodulation studies involving multiple SEMR testing sessions following a SCI.
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Affiliation(s)
- Pawan Sharma
- Division of Rehabilitation Sciences, Department of Physical Therapy, School of Health Technology and Management, University of Louisville, Louisville, KY, USA.
- Kentucky Spinal Cord Injury Research Center, University of Louisville, 220 Abraham Flexner Way, Louisville, KY, 40202, USA.
| | - Hema Rampersaud
- Department of Physiology and Biophysics, Stony Brook University, Stony Brook, NY, 11727, USA
| | - Prithvi K Shah
- Division of Rehabilitation Sciences, Department of Physical Therapy, School of Health Technology and Management, University of Louisville, Louisville, KY, USA
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Takano K, Yamaguchi T, Kikuma K, Okuyama K, Katagiri N, Sato T, Tanabe S, Kondo K, Fujiwara T. Transcutaneous spinal cord stimulation phase-dependently modulates spinal reciprocal inhibition induced by pedaling in healthy individuals. Exp Brain Res 2024; 242:2645-2652. [PMID: 39331051 DOI: 10.1007/s00221-024-06926-4] [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: 07/26/2024] [Accepted: 09/09/2024] [Indexed: 09/28/2024]
Abstract
Reciprocal inhibition (RI) between leg muscles is crucial for smooth movement. Pedaling is a rhythmic movement that can increase RI in healthy individuals. Transcutaneous spinal cord stimulation (tSCS) stimulates spinal neural circuits by targeting the afferent fibers. Pedaling with simultaneous tSCS may modulate the plasticity of the spinal neural circuit and alter neural activity based on movement and muscle engagement. This study investigated the RI changes after pedaling and tSCS and determined the phase of pedaling in which tSCS should be applied for optimal RI modulation in healthy individuals. Eleven subjects underwent three interventions: pedaling combined with tSCS during the early phase of lower extension (phase 1), pedaling combined with tSCS during the late phase of lower flexion (phase 4) of the pedaling cycle, and pedaling combined with sham tSCS. The RI from the tibialis anterior to the soleus muscle was assessed before, immediately after, 15 min, and 30 min after the intervention. RI increased immediately after phase 4 and pedaling combined with sham tSCS, whereas no changes were observed after phase 1. These results demonstrate that tSCS modulates RI changes induced by pedaling in a stimulus phase-dependent manner in healthy individuals. However, the mechanism involved in this intervention needs to be explored to achieve higher efficacy.
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Affiliation(s)
- Keita Takano
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Tomofumi Yamaguchi
- Department of Physical Therapy, Juntendo University, Faculty of Health Science, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
- Department of Physical Therapy, Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Kano Kikuma
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Kohei Okuyama
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Natsuki Katagiri
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Takatsugu Sato
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Shigeo Tanabe
- Faculty of Rehabilitation, School of Health Sciences, Fujita Health University, Aichi, Japan
| | - Kunitsugu Kondo
- Department of Rehabilitation Medicine, Tokyo Bay Rehabilitation Hospital, Chiba, Japan
| | - Toshiyuki Fujiwara
- Department of Rehabilitation Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Physical Therapy, Juntendo University, Faculty of Health Science, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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McKenzie K, Veit N, Aalla S, Yang C, Giffhorn M, Lynott A, Buchler K, Kishta A, Barry A, Sandhu M, Moon Y, Rymer WZ, Jayaraman A. Combining Neuromodulation Strategies in Spinal Cord Injury Gait Rehabilitation: A Proof of Concept, Randomized, Crossover Trial. Arch Phys Med Rehabil 2024; 105:1930-1937. [PMID: 38969255 DOI: 10.1016/j.apmr.2024.06.011] [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: 01/09/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVES To evaluate if acute intermittent hypoxia (AIH) coupled with transcutaneous spinal cord stimulation (tSCS) enhances task-specific training and leads to superior and more sustained gait improvements as compared with each of these strategies used in isolation in persons with chronic, incomplete spinal cord injury. DESIGN Proof of concept, randomized crossover trial. SETTING Outpatient, rehabilitation hospital. INTERVENTIONS Ten participants completed 3 intervention arms: (1) AIH, tSCS, and gait training (AIH + tSCS); (2) tSCS plus gait training (SHAM AIH + tSCS); and (3) gait training alone (SHAM + SHAM). Each arm consisted of 5 consecutive days of intervention with a minimum of a 4-week washout between arms. The order of arms was randomized. The study took place from December 3, 2020, to January 4, 2023. MAIN OUTCOME MEASURES 10-meter walk test at self-selected velocity (SSV) and fast velocity, 6-minute walk test, timed Up and Go (TUG) and secondary outcome measures included isometric ankle plantarflexion and dorsiflexion torque RESULTS: TUG improvements were 3.44 seconds (95% CI: 1.24-5.65) significantly greater in the AIH + tSCS arm than the SHAM AIH + tSCS arm at post-intervention (POST), and 3.31 seconds (95% CI: 1.03-5.58) greater than the SHAM + SHAM arm at 1-week follow up (1WK). SSV was 0.08 m/s (95% CI: 0.02-0.14) significantly greater following the AIH + tSCS arm than the SHAM AIH + tSCS at POST. Although not significant, the AIH + tSCS arm also demonstrated the greatest average improvements compared with the other 2 arms at POST and 1WK for the 6-minute walk test, fast velocity, and ankle plantarflexion torque. CONCLUSIONS This pilot study is the first to demonstrate that combining these 3 neuromodulation strategies leads to superior improvements in the TUG and SSV for individuals with chronic incomplete spinal cord injury and warrants further investigation.
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Affiliation(s)
| | - Nicole Veit
- Shirley Ryan AbilityLab, Chicago; Department of Biomedical Engineering, Northwestern University, Evanston
| | | | - Chen Yang
- Shirley Ryan AbilityLab, Chicago; Feinberg School of Medicine, Northwestern University, Chicago
| | | | | | | | | | | | - Milap Sandhu
- Shirley Ryan AbilityLab, Chicago; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago
| | - Yaejin Moon
- Shirley Ryan AbilityLab, Chicago; Feinberg School of Medicine, Northwestern University, Chicago
| | - William Zev Rymer
- Shirley Ryan AbilityLab, Chicago; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago; Department of Neuroscience, Feinberg School of Medicine, Northwestern University, Chicago
| | - Arun Jayaraman
- Shirley Ryan AbilityLab, Chicago; Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago.
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Scheffler MS, Martin CA, Dietz V, Faraji AH, Sayenko DG. Synergistic implications of combinatorial rehabilitation approaches using spinal stimulation on therapeutic outcomes in spinal cord injury. Clin Neurophysiol 2024; 165:166-179. [PMID: 39033698 PMCID: PMC11325878 DOI: 10.1016/j.clinph.2024.06.015] [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: 01/17/2024] [Revised: 06/07/2024] [Accepted: 06/26/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVE The objective of this narrative review was to locate and assess recent articles employing a combinatorial approach of transcutaneous spinal cord stimulation or epidural spinal cord stimulation with additional modalities. We sought to provide relevant knowledge of recent literature and advance understanding on outcomes reported, to better equip those working in neurorehabilitation and neuromodulation. METHODS Articles were selected and analyzed based on study approach, stimulation parameters, outcome measures, and presence of neurophysiological data to support findings. RESULTS This narrative review analyzed 44 recent articles employing a combinatorial approach of transcutaneous spinal cord stimulation or epidural spinal cord stimulation with additional modalities. Our findings showed that limited research exists regarding such combinatorial approaches, particularly when considering modalities beyond activity-based training. There is also limited consistency in neurophysiological and quality of life outcomes. CONCLUSION Articles involving transcutaneous spinal cord stimulation or epidural spinal cord stimulation with other modalities are limited in the current body of literature. Authors noted variety in approach, sample size, and use of participant perspective. Opportunities are present to add high quality research to this body of literature. SIGNIFICANCE Transcutaneous spinal cord stimulation and epidural spinal cord stimulation are emerging in research as viable avenues for targeting improvement of function after traumatic spinal cord injury, particularly when combined with activity-based training. This body of literature demonstrates viable areas for growth from both neurophysiological and functional perspectives. Further, exploration of novel combinatorial approaches holds potential to offer enhanced contributions to clinical and neurophysiological rehabilitation and research.
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Affiliation(s)
- Michelle S Scheffler
- Department of Neurosurgery, Houston Methodist Research Institute, 6670 Bertner Ave, Houston, TX, 77030, USA
| | - Catherine A Martin
- Department of Neurosurgery, Houston Methodist Research Institute, 6670 Bertner Ave, Houston, TX, 77030, USA
| | - Valerie Dietz
- Department of Neurosurgery, Houston Methodist Research Institute, 6670 Bertner Ave, Houston, TX, 77030, USA
| | - Amir H Faraji
- Department of Neurosurgery, Houston Methodist Research Institute, 6670 Bertner Ave, Houston, TX, 77030, USA
| | - Dimitry G Sayenko
- Department of Neurosurgery, Houston Methodist Research Institute, 6670 Bertner Ave, Houston, TX, 77030, USA.
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Bikchentaeva L, Nikulina M, Shulman A, Baltin M, Zheltukhina A, Semenova E, Smirnova V, Klepikova S, Baltina T. Different Factors Influencing Postural Stability during Transcutaneous Electrical Stimulation of the Cervical Spinal Cord. J Funct Morphol Kinesiol 2024; 9:142. [PMID: 39311250 PMCID: PMC11417861 DOI: 10.3390/jfmk9030142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2024] [Revised: 08/17/2024] [Accepted: 08/19/2024] [Indexed: 09/26/2024] Open
Abstract
Transcutaneous spinal cord stimulation (tSCS) is a promising noninvasive alternative to epidural stimulation. However, further studies are needed to clarify how tSCS affects postural control. The aim of this study was to investigate the effect of transcutaneous cervical spinal cord stimulation on postural stability in healthy participants via computerized stabilization. The center of pressure and the frequency spectrum of the statokinesiogram were assessed in 14 healthy volunteers under tSCS conditions with frequencies of 5 Hz or 30 Hz, subthreshold or suprathreshold stimulus strength, open or closed eyes, and hard or soft surfaces in various combinations. The results revealed that not all the changes in the center of the pressure oscillations reached statistical significance when the tSCS was used. However, tSCS at a frequency of 30 Hz with a suprathreshold stimulus strength improved postural stability. The use of subthreshold or suprathreshold tSCS at 5 Hz led to a shift of 60% of the signal power to the low-frequency range, indicating activation of the vestibular system. With tSCS at 30 Hz, the vestibular component remained dominant, but a decrease in the proportion of high-frequency oscillations was observed, which is associated with muscle proprioception. Thus, transcutaneous electrical stimulation of the cervical spinal cord may be an effective method for activating spinal cord neural networks capable of modulating postural control.
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Affiliation(s)
- Leisan Bikchentaeva
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
| | - Margarita Nikulina
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
| | - Anna Shulman
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
| | - Maxim Baltin
- Sport Science Department, Sirius University of Science and Technology, Olympic Ave. 1, 354349 Sirius Federal Territory, Russia;
| | - Angelina Zheltukhina
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
| | - Elena Semenova
- Lobachevskii Institute of Mathematics and Mechanics, Kazan Federal University, Kremlevskaya 35, 420008 Kazan, Russia; (E.S.); (V.S.)
| | - Viktoriya Smirnova
- Lobachevskii Institute of Mathematics and Mechanics, Kazan Federal University, Kremlevskaya 35, 420008 Kazan, Russia; (E.S.); (V.S.)
| | - Svetlana Klepikova
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
| | - Tatyana Baltina
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Karla Marksa 76, 420015 Kazan, Russia; (L.B.); (M.N.); (A.S.); (A.Z.)
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10
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Parhizi B, Barss TS, Dineros AM, Sivadasan G, Mann D, Mushahwar VK. Bimanual coordination and spinal cord neuromodulation: how neural substrates of bimanual movements are altered by transcutaneous spinal cord stimulation. J Neuroeng Rehabil 2024; 21:103. [PMID: 38890742 PMCID: PMC11184732 DOI: 10.1186/s12984-024-01395-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 05/30/2024] [Indexed: 06/20/2024] Open
Abstract
Humans use their arms in complex ways that often demand two-handed coordination. Neurological conditions limit this impressive feature of the human motor system. Understanding how neuromodulatory techniques may alter neural mechanisms of bimanual coordination is a vital step towards designing efficient rehabilitation interventions. By non-invasively activating the spinal cord, transcutaneous spinal cord stimulation (tSCS) promotes recovery of motor function after spinal cord injury. A multitude of research studies have attempted to capture the underlying neural mechanisms of these effects using a variety of electrophysiological tools, but the influence of tSCS on cortical rhythms recorded via electroencephalography remains poorly understood, especially during bimanual actions. We recruited 12 neurologically intact participants to investigate the effect of cervical tSCS on sensorimotor cortical oscillations. We examined changes in the movement kinematics during the application of tSCS as well as the cortical activation level and interhemispheric connectivity during the execution of unimanual and bimanual arm reaching movements that represent activities of daily life. Behavioral assessment of the movements showed improvement of movement time and error during a bimanual common-goal movement when tSCS was delivered, but no difference was found in the performance of unimanual and bimanual dual-goal movements with the application of tSCS. In the alpha band, spectral power was modulated with tSCS in the direction of synchronization in the primary motor cortex during unimanual and bimanual dual-goal movements and in the somatosensory cortex during unimanual movements. In the beta band, tSCS significantly increased spectral power in the primary motor and somatosensory cortices during the performance of bimanual common-goal and unimanual movements. A significant increase in interhemispheric connectivity in the primary motor cortex in the alpha band was only observed during unimanual tasks in the presence of tSCS. Our observations provide, for the first time, information regarding the supra-spinal effects of tSCS as a neuromodulatory technique applied to the spinal cord during the execution of bi- and unimanual arm movements. They also corroborate the suppressive effect of tSCS at the cortical level reported in previous studies. These findings may guide the design of improved rehabilitation interventions using tSCS for the recovery of upper-limb function in the future.
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Affiliation(s)
- Behdad Parhizi
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada
| | - Trevor S Barss
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Katz Group-Rexall Centre for Pharmacy and Health Research, University of Alberta, Edmonton, AB, T6G 2E1, Canada
| | - Alphonso Martin Dineros
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
| | - Gokul Sivadasan
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada
- Department of Electrical and Computer Engineering, University of Alberta, Edmonton, AB, Canada
| | - Darren Mann
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Vivian K Mushahwar
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
- Institute for Smart Augmentative and Restorative Technologies and Health Innovation (iSMART), University of Alberta, Edmonton, AB, Canada.
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Katz Group-Rexall Centre for Pharmacy and Health Research, University of Alberta, Edmonton, AB, T6G 2E1, Canada.
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11
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Moritz C, Field-Fote EC, Tefertiller C, van Nes I, Trumbower R, Kalsi-Ryan S, Purcell M, Janssen TWJ, Krassioukov A, Morse LR, Zhao KD, Guest J, Marino RJ, Murray LM, Wecht JM, Rieger M, Pradarelli J, Turner A, D'Amico J, Squair JW, Courtine G. Non-invasive spinal cord electrical stimulation for arm and hand function in chronic tetraplegia: a safety and efficacy trial. Nat Med 2024; 30:1276-1283. [PMID: 38769431 PMCID: PMC11108781 DOI: 10.1038/s41591-024-02940-9] [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: 12/01/2023] [Accepted: 03/22/2024] [Indexed: 05/22/2024]
Abstract
Cervical spinal cord injury (SCI) leads to permanent impairment of arm and hand functions. Here we conducted a prospective, single-arm, multicenter, open-label, non-significant risk trial that evaluated the safety and efficacy of ARCEX Therapy to improve arm and hand functions in people with chronic SCI. ARCEX Therapy involves the delivery of externally applied electrical stimulation over the cervical spinal cord during structured rehabilitation. The primary endpoints were safety and efficacy as measured by whether the majority of participants exhibited significant improvement in both strength and functional performance in response to ARCEX Therapy compared to the end of an equivalent period of rehabilitation alone. Sixty participants completed the protocol. No serious adverse events related to ARCEX Therapy were reported, and the primary effectiveness endpoint was met. Seventy-two percent of participants demonstrated improvements greater than the minimally important difference criteria for both strength and functional domains. Secondary endpoint analysis revealed significant improvements in fingertip pinch force, hand prehension and strength, upper extremity motor and sensory abilities and self-reported increases in quality of life. These results demonstrate the safety and efficacy of ARCEX Therapy to improve hand and arm functions in people living with cervical SCI. ClinicalTrials.gov identifier: NCT04697472 .
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Affiliation(s)
- Chet Moritz
- Departments of Rehabilitation Medicine, Electrical & Computer Engineering, Physiology & Biophysics and Center for Neurotechnology, University of Washington, Seattle, WA, USA
| | - Edelle C Field-Fote
- Shepherd Center, Crawford Research Institute and Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Ilse van Nes
- Sint Maartenskliniek, Revalidatiegeneeskunde, Nijmegen, The Netherlands
| | - Randy Trumbower
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Sukhvinder Kalsi-Ryan
- KITE Research Institute|Toronto Rehab, University Health Network, Toronto, Ontario, Canada
| | - Mariel Purcell
- Scottish Centre for Innovation in Spinal Cord Injury, Queen Elizabeth National Spinal Injuries Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Thomas W J Janssen
- Amsterdam Rehabilitation Research Center | Reade, Amsterdam, The Netherlands
- Faculty of Behavioral and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Andrei Krassioukov
- ICORD and Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Leslie R Morse
- Department of Rehabilitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Kristin D Zhao
- Department of Physical Medicine and Rehabilitation, Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, MN, USA
| | - James Guest
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
- Miami Project to Cure Paralysis, Miami, FL, USA
| | - Ralph J Marino
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Lynda M Murray
- Departments of Rehabilitation and Human Performance and Medicine, James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Research and Development, James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jill M Wecht
- Department of Research and Development, James J. Peters VA Medical Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jessica D'Amico
- ONWARD Medical, Lausanne, Switzerland
- Glenrose Rehabilitation Hospital, Alberta Health Services, Edmonton, Alberta, Canada
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jordan W Squair
- NeuroX Institute and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland
- Defitech Center for Interventional Neurotherapies (NeuroRestore), EPFL/CHUV/UNIL, Lausanne, Switzerland
- NeuroRestore, NeuroX Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland
| | - Gregoire Courtine
- NeuroX Institute and Brain Mind Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland.
- Department of Clinical Neuroscience, Lausanne University Hospital (CHUV) and University of Lausanne (UNIL), Lausanne, Switzerland.
- Defitech Center for Interventional Neurotherapies (NeuroRestore), EPFL/CHUV/UNIL, Lausanne, Switzerland.
- NeuroRestore, NeuroX Institute, School of Life Sciences, Swiss Federal Institute of Technology (EPFL), Lausanne, Switzerland.
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12
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Davidson B, Bhattacharya A, Sarica C, Darmani G, Raies N, Chen R, Lozano AM. Neuromodulation techniques - From non-invasive brain stimulation to deep brain stimulation. Neurotherapeutics 2024; 21:e00330. [PMID: 38340524 PMCID: PMC11103220 DOI: 10.1016/j.neurot.2024.e00330] [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: 10/11/2023] [Revised: 01/14/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Over the past 30 years, the field of neuromodulation has witnessed remarkable advancements. These developments encompass a spectrum of techniques, both non-invasive and invasive, that possess the ability to both probe and influence the central nervous system. In many cases neuromodulation therapies have been adopted into standard care treatments. Transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and transcranial ultrasound stimulation (TUS) are the most common non-invasive methods in use today. Deep brain stimulation (DBS), spinal cord stimulation (SCS), and vagus nerve stimulation (VNS), are leading surgical methods for neuromodulation. Ongoing active clinical trials using are uncovering novel applications and paradigms for these interventions.
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Affiliation(s)
- Benjamin Davidson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | | | - Can Sarica
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada; Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Ghazaleh Darmani
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Nasem Raies
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
| | - Robert Chen
- Krembil Research Institute, University Health Network, Toronto, ON, Canada; Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada; Krembil Research Institute, University Health Network, Toronto, ON, Canada.
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13
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Tajali S, Balbinot G, Pakosh M, Sayenko DG, Zariffa J, Masani K. Modulations in neural pathways excitability post transcutaneous spinal cord stimulation among individuals with spinal cord injury: a systematic review. Front Neurosci 2024; 18:1372222. [PMID: 38591069 PMCID: PMC11000807 DOI: 10.3389/fnins.2024.1372222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 03/06/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction Transcutaneous spinal cord stimulation (TSCS), a non-invasive form of spinal cord stimulation, has been shown to improve motor function in individuals living with spinal cord injury (SCI). However, the effects of different types of TSCS currents including direct current (DC-TSCS), alternating current (AC-TSCS), and spinal paired stimulation on the excitability of neural pathways have not been systematically investigated. The objective of this systematic review was to determine the effects of TSCS on the excitability of neural pathways in adults with non-progressive SCI at any level. Methods The following databases were searched from their inception until June 2022: MEDLINE ALL, Embase, Web of Science, Cochrane Library, and clinical trials. A total of 4,431 abstracts were screened, and 23 articles were included. Results Nineteen studies used TSCS at the thoracolumbar enlargement for lower limb rehabilitation (gait & balance) and four studies used cervical TSCS for upper limb rehabilitation. Sixteen studies measured spinal excitability by reporting different outcomes including Hoffmann reflex (H-reflex), flexion reflex excitability, spinal motor evoked potentials (SMEPs), cervicomedullay evoked potentials (CMEPs), and cutaneous-input-evoked muscle response. Seven studies measured corticospinal excitability using motor evoked potentials (MEPs) induced by transcranial magnetic stimulation (TMS), and one study measured somatosensory evoked potentials (SSEPs) following TSCS. Our findings indicated a decrease in the amplitude of H-reflex and long latency flexion reflex following AC-TSCS, alongside an increase in the amplitudes of SMEPs and CMEPs. Moreover, the application of the TSCS-TMS paired associative technique resulted in spinal reflex inhibition, manifested by reduced amplitudes in both the H-reflex and flexion reflex arc. In terms of corticospinal excitability, findings from 5 studies demonstrated an increase in the amplitude of MEPs linked to lower limb muscles following DC-TSCS, in addition to paired associative stimulation involving repetitive TMS on the brain and DC-TSCS on the spine. There was an observed improvement in the latency of SSEPs in a single study. Notably, the overall quality of evidence, assessed by the modified Downs and Black Quality assessment, was deemed poor. Discussion This review unveils the systematic evidence supporting the potential of TSCS in reshaping both spinal and supraspinal neuronal circuitries post-SCI. Yet, it underscores the critical necessity for more rigorous, high-quality investigations.
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Affiliation(s)
- Shirin Tajali
- KITE Research Institute – University Health Network, Toronto, ON, Canada
| | - Gustavo Balbinot
- KITE Research Institute – University Health Network, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application – CRANIA, University Health Network, Toronto, ON, Canada
| | - Maureen Pakosh
- Library & Information Services, University Health Network, Toronto Rehabilitation Institute, ON, Canada
| | - Dimitry G. Sayenko
- Department of Neurosurgery, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, TX, United States
| | - Jose Zariffa
- KITE Research Institute – University Health Network, Toronto, ON, Canada
- Edward S. Rogers Sr. Department of Electrical and Computer Engineering, University of Toronto, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
| | - Kei Masani
- KITE Research Institute – University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
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14
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Hosseini SM, Borys B, Karimi-Abdolrezaee S. Neural stem cell therapies for spinal cord injury repair: an update on recent preclinical and clinical advances. Brain 2024; 147:766-793. [PMID: 37975820 DOI: 10.1093/brain/awad392] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 10/22/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
Traumatic spinal cord injury (SCI) is a leading cause of lifelong disabilities. Permanent sensory, motor and autonomic impairments after SCI are substantially attributed to degeneration of spinal cord neurons and axons, and disintegration of neural network. To date, minimal regenerative treatments are available for SCI with an unmet need for new therapies to reconstruct the damaged spinal cord neuron-glia network and restore connectivity with the supraspinal pathways. Multipotent neural precursor cells (NPCs) have a unique capacity to generate neurons, oligodendrocytes and astrocytes. Due to this capacity, NPCs have been an attractive cell source for cellular therapies for SCI. Transplantation of NPCs has been extensively tested in preclinical models of SCI in the past two decades. These studies have identified opportunities and challenges associated with NPC therapies. While NPCs have the potential to promote neuroregeneration through various mechanisms, their low long-term survival and integration within the host injured spinal cord limit the functional benefits of NPC-based therapies for SCI. To address this challenge, combinatorial strategies have been developed to optimize the outcomes of NPC therapies by enriching SCI microenvironment through biomaterials, genetic and pharmacological therapies. In this review, we will provide an in-depth discussion on recent advances in preclinical NPC-based therapies for SCI. We will discuss modes of actions and mechanism by which engrafted NPCs contribute to the repair process and functional recovery. We will also provide an update on current clinical trials and new technologies that have facilitated preparation of medical-grade human NPCs suitable for transplantation in clinical studies.
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Affiliation(s)
- Seyed Mojtaba Hosseini
- Department of Physiology and Pathophysiology, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba Winnipeg, Manitoba R3E 0J9, Canada
- Manitoba Multiple Sclerosis Research Center, Winnipeg, Manitoba R3E 0J9, Canada
| | - Ben Borys
- Department of Physiology and Pathophysiology, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba Winnipeg, Manitoba R3E 0J9, Canada
| | - Soheila Karimi-Abdolrezaee
- Department of Physiology and Pathophysiology, Spinal Cord Research Centre, Rady Faculty of Health Sciences, University of Manitoba Winnipeg, Manitoba R3E 0J9, Canada
- Manitoba Multiple Sclerosis Research Center, Winnipeg, Manitoba R3E 0J9, Canada
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba R3E 3P4, Canada
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15
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Kawai K, Tazoe T, Yanai T, Kazuyuki K, Nishimura Y. Transsynaptic activation of human lumbar spinal motoneurons by transvertebral magnetic stimulation. Neurosci Res 2024; 200:20-27. [PMID: 37793496 DOI: 10.1016/j.neures.2023.10.001] [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: 08/14/2023] [Revised: 09/15/2023] [Accepted: 10/01/2023] [Indexed: 10/06/2023]
Abstract
Noninvasive spinal stimulation has been increasingly used in research on motor control and neurorehabilitation. Despite advances in percutaneous electrical stimulation techniques, magnetic stimulation is not as commonly used as electrical stimulation. Therefore, it is still under discussion what neuronal elements are activated by magnetic stimulation of the human spinal cord. In this study, we demonstrated that transvertebral magnetic stimulation (TVMS) induced transsynaptic activation of spinal motoneuron pools in the lumbar cord. In healthy humans, paired-pulse TVMS was given over an intervertebral space between the L1-L2 vertebrae with an interpulse interval of 100 ms, and the stimulus-evoked electromyographic (EMG) responses were recorded in the lower limb muscles. The results show that the evoked EMG responses after the 2nd pulse were clearly suppressed compared with the widespread responses evoked after the 1st pulse in the muscles of the lower extremity, indicating that the transsynaptic activation of spinal motoneurons by the 2nd pulse was suppressed by the effects produced by the 1st pulse. The inconsistent modulation of response suppression to stimulus intensity across individuals suggests that the TVMS-evoked EMG responses are composed of the compound potentials mediated by the direct activation of motor axons and the transsynaptic activation of motoneuron pools through sensory afferents and that the recruitment order of those fibers by TVMS may be nonhomogeneous across individuals.
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Affiliation(s)
- Kazutake Kawai
- College of Sports Sciences, Nihon University, Setagaya, Tokyo 154-8513, Japan; Neural Prosthetics Project, Department of Brain and Neuroscience, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo 156-8506, Japan; Faculty of Sport Sciences, Waseda University, Tokorozawa, Saitama 359-1192, Japan
| | - Toshiki Tazoe
- Neural Prosthetics Project, Department of Brain and Neuroscience, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo 156-8506, Japan.
| | - Toshimasa Yanai
- Faculty of Sport Sciences, Waseda University, Tokorozawa, Saitama 359-1192, Japan
| | - Kanosue Kazuyuki
- Faculty of Sport Sciences, Waseda University, Tokorozawa, Saitama 359-1192, Japan
| | - Yukio Nishimura
- Neural Prosthetics Project, Department of Brain and Neuroscience, Tokyo Metropolitan Institute of Medical Science, Setagaya, Tokyo 156-8506, Japan
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16
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Massey S, Konig D, Upadhyay P, Evcil ZB, Melin R, Fatima M, Hannah R, Duffell L. The effects of transcutaneous spinal cord stimulation delivered with and without high-frequency modulation on spinal and corticospinal excitability. Artif Organs 2024; 48:297-308. [PMID: 37840354 DOI: 10.1111/aor.14660] [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: 02/23/2023] [Revised: 09/14/2023] [Accepted: 09/25/2023] [Indexed: 10/17/2023]
Abstract
Transcutaneous spinal cord stimulation (TSCS) has been shown to improve motor recovery in people with spinal cord injury (SCI). Some groups deliver TSCS modulated with a kHz-frequency (TSCS-kHz); the intensity used for TSCS-kHz is usually set based on the motor threshold for TSCS, even though TSCS-kHz threshold is considerably higher than TSCS. As a result, TSCS-kHz interventions tend to be delivered at low intensities with respect to the motor threshold (~40%). In this study, we compared the effects of sub-threshold TSCS and TSCS-kHz, when delivered at similar intensity relative to their own motor threshold. Experiment I compared the after-effects of 20 min of sub-threshold (40% threshold) TSCS and TSCS-kHz on spinal and corticospinal excitability in able-bodied participants. Experiment II assessed the dose-response relationship of delivering short (10-pulse) trains of TSCS and TSCS-kHz at three different current intensities relative to the threshold (40%, 60%, and 80%). Experiment I found that 20 min of TSCS-kHz at a 40% threshold decreased posterior root reflex amplitude (p < 0.05), whereas TSCS did not. In experiment II, motor-evoked potential (MEP) amplitude increased following short trains of TSCS and TSCS-kHz of increasing intensity. MEP amplitude was significantly greater for TSCS-kHz compared with TSCS when delivered at 80% of the threshold (p < 0.05). These results suggest that TSCS and TSCS-kHz have different effects when delivered at similar intensity relative to their own threshold; both for immediate effects on corticospinal excitability and following prolonged stimulation on spinal excitability. These different effects may be utilized for optimal rehabilitation in people with SCI.
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Affiliation(s)
- Sarah Massey
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
- Aspire Centre for Rehabilitation Engineering and Assistive Technology, UCL Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, London, UK
| | - Danielle Konig
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Pratham Upadhyay
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Zehra Beril Evcil
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Rebbekha Melin
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Memoona Fatima
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
| | - Ricci Hannah
- Centre for Human and Applied Physiological Sciences, Kings College London, London, UK
| | - Lynsey Duffell
- Department of Medical Physics & Biomedical Engineering, University College London, London, UK
- Aspire Centre for Rehabilitation Engineering and Assistive Technology, UCL Institute of Orthopaedics and Musculoskeletal Sciences, Royal National Orthopaedic Hospital, London, UK
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17
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Allen JR, Karri SR, Yang C, Stoykov ME. Spinal Cord Stimulation for Poststroke Hemiparesis: A Scoping Review. Am J Occup Ther 2024; 78:7802180220. [PMID: 38477681 PMCID: PMC11017736 DOI: 10.5014/ajot.2024.050533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
IMPORTANCE Spinal cord stimulation (SCS) is a neuromodulation technique that can improve paresis in individuals with spinal cord injury. SCS is emerging as a technique that can address upper and lower limb hemiparesis. Little is understood about its effectiveness with the poststroke population. OBJECTIVE To summarize the evidence for SCS after stroke and any changes in upper extremity and lower extremity motor function. DATA SOURCES PubMed, Web of Science, Embase, and CINAHL. The reviewers used hand searches and reference searches of retrieved articles. There were no limitations regarding publication year. STUDY SELECTION AND DATA COLLECTION This review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The inclusion and exclusion criteria included a broad range of study characteristics. Studies were excluded if the intervention did not meet the definition of SCS intervention, used only animals or healthy participants, did not address upper or lower limb motor function, or examined neurological conditions other than stroke. FINDINGS Fourteen articles met the criteria for this review. Seven studies found a significant improvement in motor function in groups receiving SCS. CONCLUSIONS AND RELEVANCE Results indicate that SCS may provide an alternative means to improve motor function in the poststroke population. Plain-Language Summary: The results of this study show that spinal cord stimulation may provide an alternative way to improve motor function after stroke. Previous neuromodulation methods have targeted the impaired supraspinal circuitry after stroke. Although downregulated, spinal cord circuitry is largely intact and offers new possibilities for motor recovery.
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Affiliation(s)
- Jonathan R Allen
- Jonathan R. Allen, OTD, OTR/L, is Occupational Therapist, Corewell Health, Grand Rapids, MI. At the time of the study, Allen was Doctoral Student, Department of Occupational Therapy, College of Health Sciences, University of Michigan-Flint;
| | - Swathi R Karri
- Swathi R. Karri, is Osteopathic Medical Student II, Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL
| | - Chen Yang
- Chen Yang, PhD, is Postdoctoral Fellow, Max Näder Lab for Rehabilitation Technologies and Outcomes Research, Shirley Ryan AbilityLab, Chicago, IL, and Postdoctoral Fellow, Physical Medicine & Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Mary Ellen Stoykov
- Mary Ellen Stoykov, PhD, OTR/L, is Research Scientist, Arms + Hands Lab, Shirley Ryan AbilityLab, Chicago, IL, and Research Associate Professor, Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
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Spieker EL, Dvorani A, Salchow-Hömmen C, Otto C, Ruprecht K, Wenger N, Schauer T. Targeting Transcutaneous Spinal Cord Stimulation Using a Supervised Machine Learning Approach Based on Mechanomyography. SENSORS (BASEL, SWITZERLAND) 2024; 24:634. [PMID: 38276326 PMCID: PMC10818383 DOI: 10.3390/s24020634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
Transcutaneous spinal cord stimulation (tSCS) provides a promising therapy option for individuals with injured spinal cords and multiple sclerosis patients with spasticity and gait deficits. Before the therapy, the examiner determines a suitable electrode position and stimulation current for a controlled application. For that, amplitude characteristics of posterior root muscle (PRM) responses in the electromyography (EMG) of the legs to double pulses are examined. This laborious procedure holds potential for simplification due to time-consuming skin preparation, sensor placement, and required expert knowledge. Here, we investigate mechanomyography (MMG) that employs accelerometers instead of EMGs to assess muscle activity. A supervised machine-learning classification approach was implemented to classify the acceleration data into no activity and muscular/reflex responses, considering the EMG responses as ground truth. The acceleration-based calibration procedure achieved a mean accuracy of up to 87% relative to the classical EMG approach as ground truth on a combined cohort of 11 healthy subjects and 11 patients. Based on this classification, the identified current amplitude for the tSCS therapy was in 85%, comparable to the EMG-based ground truth. In healthy subjects, where both therapy current and position have been identified, 91% of the outcome matched well with the EMG approach. We conclude that MMG has the potential to make the tuning of tSCS feasible in clinical practice and even in home use.
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Affiliation(s)
- Eira Lotta Spieker
- Department of Neurology, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; (E.L.S.); (C.S.-H.); (C.O.); (K.R.); (N.W.)
- Control Systems Group, Technische Universität Berlin, Einsteinufer 17, 10587 Berlin, Germany;
- SensorStim Neurotechnology GmbH, c/o TU Berlin, Einsteinufer 17, 10587 Berlin, Germany
| | - Ardit Dvorani
- Control Systems Group, Technische Universität Berlin, Einsteinufer 17, 10587 Berlin, Germany;
- SensorStim Neurotechnology GmbH, c/o TU Berlin, Einsteinufer 17, 10587 Berlin, Germany
| | - Christina Salchow-Hömmen
- Department of Neurology, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; (E.L.S.); (C.S.-H.); (C.O.); (K.R.); (N.W.)
| | - Carolin Otto
- Department of Neurology, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; (E.L.S.); (C.S.-H.); (C.O.); (K.R.); (N.W.)
| | - Klemens Ruprecht
- Department of Neurology, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; (E.L.S.); (C.S.-H.); (C.O.); (K.R.); (N.W.)
| | - Nikolaus Wenger
- Department of Neurology, Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany; (E.L.S.); (C.S.-H.); (C.O.); (K.R.); (N.W.)
| | - Thomas Schauer
- Control Systems Group, Technische Universität Berlin, Einsteinufer 17, 10587 Berlin, Germany;
- SensorStim Neurotechnology GmbH, c/o TU Berlin, Einsteinufer 17, 10587 Berlin, Germany
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Oh J, Scheffler MS, Mahan EE, King ST, Martin CA, Dinh J, Steele AG, O'Malley MK, Sayenko DG. Combinatorial Effects of Transcutaneous Spinal Stimulation and Task-Specific Training to Enhance Hand Motor Output after Paralysis. Top Spinal Cord Inj Rehabil 2023; 29:15-22. [PMID: 38174129 PMCID: PMC10759855 DOI: 10.46292/sci23-00040s] [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: 01/05/2024]
Abstract
Background Despite the positive results in upper limb (UL) motor recovery after using electrical neuromodulation in individuals after cervical spinal cord injury (SCI) or stroke, there has been limited exploration of potential benefits of combining task-specific hand grip training with transcutaneous electrical spinal stimulation (TSS) for individuals with UL paralysis. Objectives This study investigates the combinatorial effects of task-specific hand grip training and noninvasive TSS to enhance hand motor output after paralysis. Methods Four participants with cervical SCI classified as AIS A and B and two participants with cerebral stroke were recruited in this study. The effects of cervical TSS without grip training and during training with sham stimulation were contrasted with hand grip training with TSS. TSS was applied at midline over cervical spinal cord. During hand grip training, 5 to 10 seconds of voluntary contraction were repeated at a submaximum strength for approximately 10 minutes, three days per week for 4 weeks. Signals from hand grip dynamometer along with the electromyography (EMG) activity from UL muscles were recorded and displayed as visual feedback. Results Our case study series demonstrated that combined task-specific hand grip training and cervical TSS targeting the motor pools of distal muscles in the UL resulted in significant improvements in maximum hand grip strength. However, TSS alone or hand grip training alone showed limited effectiveness in improving grip strength. Conclusion Task-specific hand grip training combined with TSS can result in restoration of hand motor function in paralyzed upper limbs in individuals with cervical SCI and stroke.
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Affiliation(s)
- Jeonghoon Oh
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
| | - Michelle S. Scheffler
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
| | - Erin E. Mahan
- Department of Mechanical Engineering, Rice University, Houston, Texas, USA
| | - Shane T. King
- Department of Mechanical Engineering, Rice University, Houston, Texas, USA
| | - Catherine A. Martin
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
| | - Jenny Dinh
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
| | - Alexander G. Steele
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
| | - Marcia K. O'Malley
- Department of Mechanical Engineering, Rice University, Houston, Texas, USA
| | - Dimitry G. Sayenko
- Department of Neurosurgery, Center for Translational Neural Prosthetics and Interfaces, Center for Neuroregeneration, Houston Methodist Research Institute, Houston, Texas, USA
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20
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Tian T, Zhang S, Yang M. Recent progress and challenges in the treatment of spinal cord injury. Protein Cell 2023; 14:635-652. [PMID: 36856750 PMCID: PMC10501188 DOI: 10.1093/procel/pwad003] [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: 11/21/2022] [Accepted: 12/29/2022] [Indexed: 02/12/2023] Open
Abstract
Spinal cord injury (SCI) disrupts the structural and functional connectivity between the higher center and the spinal cord, resulting in severe motor, sensory, and autonomic dysfunction with a variety of complications. The pathophysiology of SCI is complicated and multifaceted, and thus individual treatments acting on a specific aspect or process are inadequate to elicit neuronal regeneration and functional recovery after SCI. Combinatory strategies targeting multiple aspects of SCI pathology have achieved greater beneficial effects than individual therapy alone. Although many problems and challenges remain, the encouraging outcomes that have been achieved in preclinical models offer a promising foothold for the development of novel clinical strategies to treat SCI. In this review, we characterize the mechanisms underlying axon regeneration of adult neurons and summarize recent advances in facilitating functional recovery following SCI at both the acute and chronic stages. In addition, we analyze the current status, remaining problems, and realistic challenges towards clinical translation. Finally, we consider the future of SCI treatment and provide insights into how to narrow the translational gap that currently exists between preclinical studies and clinical practice. Going forward, clinical trials should emphasize multidisciplinary conversation and cooperation to identify optimal combinatorial approaches to maximize therapeutic benefit in humans with SCI.
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Affiliation(s)
- Ting Tian
- Ministry of Education Key Laboratory of Protein Science, Beijing Advanced Innovation Center for Structural Biology, Beijing Frontier Research Center for Biological Structure, School of Life Sciences, Tsinghua University, Beijing 100084, China
| | - Sensen Zhang
- Ministry of Education Key Laboratory of Protein Science, Beijing Advanced Innovation Center for Structural Biology, Beijing Frontier Research Center for Biological Structure, School of Life Sciences, Tsinghua University, Beijing 100084, China
| | - Maojun Yang
- Ministry of Education Key Laboratory of Protein Science, Beijing Advanced Innovation Center for Structural Biology, Beijing Frontier Research Center for Biological Structure, School of Life Sciences, Tsinghua University, Beijing 100084, China
- Cryo-EM Facility Center, Southern University of Science and Technology, Shenzhen 518055, China
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21
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Capozio A, Ichiyama R, Astill SL. The acute effects of motor imagery and cervical transcutaneous electrical stimulation on manual dexterity and neural excitability. Neuropsychologia 2023; 187:108613. [PMID: 37285931 DOI: 10.1016/j.neuropsychologia.2023.108613] [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: 02/14/2023] [Revised: 05/01/2023] [Accepted: 06/04/2023] [Indexed: 06/09/2023]
Abstract
Transcutaneous electrical stimulation (TCES) of the spinal cord induces changes in spinal excitability. Motor imagery (MI) elicits plasticity in the motor cortex. It has been suggested that plasticity occurring in both cortical and spinal circuits might underlie the improvements in performance observed when training is combined with stimulation. We investigated the acute effects of cervical TCES and MI delivered in isolation or combined on corticospinal excitability, spinal excitability and manual performance. Participants (N = 17) completed three sessions during which they engaged in 20 min of: 1) MI, listening to an audio recording instructing to complete the purdue pegboard test (PPT) of manual performance; 2) TCES at the spinal level of C5-C6; 3) MI + TCES, listening to the MI script while receiving TCES. Before and after each condition, we measured corticospinal excitability via transcranial magnetic stimulation (TMS) at 100% and 120% motor threshold (MT), spinal excitability via single-pulse TCES and manual performance with the PPT. Manual performance was not improved by MI, TCES or MI + TCES. Corticospinal excitability assessed at 100% MT intensity increased in hand and forearm muscles after MI and MI + TCES, but not after just TCES. Conversely, corticospinal excitability assessed at 120% MT intensity was not affected by any of the conditions. The effects on spinal excitability depended on the recorded muscle: it increased after all conditions in biceps brachii (BB) and flexor carpi radialis (FCR); did not change after any conditions in the abductor pollicis brevis (APB); increased after TCES and MI + TCES, but not after just MI in the extensor carpi radialis (ECR). These findings suggest that MI and TCES increase the excitability of the central nervous system through different but complementary mechanisms, inducing changes in the excitability of spinal and cortical circuits. MI and TCES can be used in combination to modulate spinal/cortical excitability, an approach particularly relevant for people with limited residual dexterity who cannot engage in motor practice.
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Affiliation(s)
- Antonio Capozio
- School of Biomedical Sciences, University of Leeds, United Kingdom.
| | - Ronaldo Ichiyama
- School of Biomedical Sciences, University of Leeds, United Kingdom
| | - Sarah L Astill
- School of Biomedical Sciences, University of Leeds, United Kingdom
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22
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Chandrasekaran S, Bhagat NA, Ramdeo R, Ebrahimi S, Sharma PD, Griffin DG, Stein A, Harkema SJ, Bouton CE. Case study: persistent recovery of hand movement and tactile sensation in peripheral nerve injury using targeted transcutaneous spinal cord stimulation. Front Neurosci 2023; 17:1210544. [PMID: 37529233 PMCID: PMC10390294 DOI: 10.3389/fnins.2023.1210544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/26/2023] [Indexed: 08/03/2023] Open
Abstract
Peripheral nerve injury can lead to chronic pain, paralysis, and loss of sensation, severely affecting quality of life. Spinal cord stimulation has been used in the clinic to provide pain relief arising from peripheral nerve injuries, however, its ability to restore function after peripheral nerve injury have not been explored. Neuromodulation of the spinal cord through transcutaneous spinal cord stimulation (tSCS), when paired with activity-based training, has shown promising results towards restoring volitional limb control in people with spinal cord injury. We show, for the first time, the effectiveness of targeted tSCS in restoring strength (407% increase from 1.79 ± 1.24 N to up to 7.3 ± 0.93 N) and significantly increasing hand dexterity in an individual with paralysis due to a peripheral nerve injury (PNI). Furthermore, this is the first study to document a persisting 3-point improvement during clinical assessment of tactile sensation in peripheral injury after receiving 6 weeks of tSCS. Lastly, the motor and sensory gains persisted for several months after stimulation was received, suggesting tSCS may lead to long-lasting benefits, even in PNI. Non-invasive spinal cord stimulation shows tremendous promise as a safe and effective therapeutic approach with broad applications in functional recovery after debilitating injuries.
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Affiliation(s)
- Santosh Chandrasekaran
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Nikunj A. Bhagat
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, Houston, TX, United States
| | - Richard Ramdeo
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sadegh Ebrahimi
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Pawan D. Sharma
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Doug G. Griffin
- Northwell Health STARS Rehabilitation, East Meadow, NY, United States
| | - Adam Stein
- Department of Physical Medicine and Rehabilitation, Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Manhasset, NY, United States
| | - Susan J. Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of Bioengineering, University of Louisville, Louisville, KY, United States
- Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, United States
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
| | - Chad E. Bouton
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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23
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Ovechkin A, Moshonkina T, Shandybina N, Lyakhovetskii V, Gorodnichev R, Moiseev S, Siu R, Gerasimenko Y. Transcutaneous Spinal Cord Stimulation Facilitates Respiratory Functional Performance in Patients with Post-Acute COVID-19. Life (Basel) 2023; 13:1563. [PMID: 37511940 PMCID: PMC10381407 DOI: 10.3390/life13071563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND A growing number of studies have reported Coronavirus disease (COVID-19) related to both respiratory and central nervous system dysfunctions. This study evaluates the neuromodulatory effects of spinal cord transcutaneous stimulation (scTS) on the respiratory functional state in healthy controls and patients with post-COVID-19 respiratory deficits as a step toward the development of a rehabilitation strategy for these patients. METHODS In this before-after, interventional, case-controlled clinical study, ten individuals with post-acute COVID-19 respiratory deficits and eight healthy controls received a single twenty-minute-long session of modulated monophasic scTS delivered over the T5 and T10 spinal cord segments. Forced vital capacity (FVC), peak forced inspiratory flow (PIF), peak expiratory flow (PEF), time-to-peak of inspiratory flow (tPIF), and time-to-peak of expiratory flow (tPEF), as indirect measures of spinal motor network activity, were assessed before and after the intervention. RESULTS In the COVID-19 group, the scTS intervention led to significantly increased PIF (p = 0.040) and PEF (p = 0.049) in association with significantly decreased tPIF (p = 0.035) and tPEF (p = 0.013). In the control group, the exposure to scTS also resulted in significantly increased PIF (p = 0.010) and significantly decreased tPIF (p = 0.031). Unlike the results in the COVID-19 group, the control group had significantly decreased PEF (p = 0.028) associated with significantly increased tPEF (p = 0.036). There were no changes for FVC after scTS in both groups (p = 0.67 and p = 0.503). CONCLUSIONS In post-COVID-19 patients, scTS facilitates excitation of both inspiratory and expiratory spinal neural networks leading to an immediate improvement of respiratory functional performance. This neuromodulation approach could be utilized in rehabilitation programs for patients with COVID-19 respiratory deficits.
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Affiliation(s)
- Alexander Ovechkin
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA; (R.S.); (Y.G.)
- Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
- Department of Physiology, University of Louisville, Louisville, KY 40202, USA
| | - Tatiana Moshonkina
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 St. Petersburg, Russia; (T.M.); (N.S.); (V.L.)
| | - Natalia Shandybina
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 St. Petersburg, Russia; (T.M.); (N.S.); (V.L.)
| | - Vsevolod Lyakhovetskii
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 St. Petersburg, Russia; (T.M.); (N.S.); (V.L.)
| | - Ruslan Gorodnichev
- Velikie Luki State Academy of Physical Education and Sports, 182100 Velikie Luki, Russia; (R.G.); (S.M.)
| | - Sergey Moiseev
- Velikie Luki State Academy of Physical Education and Sports, 182100 Velikie Luki, Russia; (R.G.); (S.M.)
| | - Ricardo Siu
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA; (R.S.); (Y.G.)
- Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
| | - Yury Gerasimenko
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA; (R.S.); (Y.G.)
- Department of Physiology, University of Louisville, Louisville, KY 40202, USA
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 St. Petersburg, Russia; (T.M.); (N.S.); (V.L.)
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24
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Chandrasekaran S, Bhagat NA, Ramdeo R, Ebrahimi S, Sharma PD, Griffin DG, Stein A, Harkema SJ, Bouton CE. Targeted transcutaneous spinal cord stimulation promotes persistent recovery of upper limb strength and tactile sensation in spinal cord injury: a pilot study. Front Neurosci 2023; 17:1210328. [PMID: 37483349 PMCID: PMC10360050 DOI: 10.3389/fnins.2023.1210328] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 06/15/2023] [Indexed: 07/25/2023] Open
Abstract
Long-term recovery of limb function is a significant unmet need in people with paralysis. Neuromodulation of the spinal cord through epidural stimulation, when paired with intense activity-based training, has shown promising results toward restoring volitional limb control in people with spinal cord injury. Non-invasive neuromodulation of the cervical spinal cord using transcutaneous spinal cord stimulation (tSCS) has shown similar improvements in upper-limb motor control rehabilitation. However, the motor and sensory rehabilitative effects of activating specific cervical spinal segments using tSCS have largely remained unexplored. We show in two individuals with motor-complete SCI that targeted stimulation of the cervical spinal cord resulted in up to a 1,136% increase in exerted force, with weekly activity-based training. Furthermore, this is the first study to document up to a 2-point improvement in clinical assessment of tactile sensation in SCI after receiving tSCS. Lastly, participant gains persisted after a one-month period void of stimulation, suggesting that targeted tSCS may lead to persistent recovery of motor and sensory function.
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Affiliation(s)
- Santosh Chandrasekaran
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Nikunj A. Bhagat
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Department of Physical Medicine and Rehabilitation, University of Texas Health Science Center, Houston, TX, United States
| | - Richard Ramdeo
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Sadegh Ebrahimi
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Pawan D. Sharma
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Doug G. Griffin
- Northwell Health STARS Rehabilitation, East Meadow, NY, United States
| | - Adam Stein
- Department of Physical Medicine and Rehabilitation, Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Manhasset, NY, United States
| | - Susan J. Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of Bioengineering, University of Louisville, Louisville, KY, United States
- Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, United States
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States
| | - Chad E. Bouton
- Neural Bypass and Brain Computer Interface Laboratory, Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, United States
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25
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Brihmat N, Bayram MB, Ravi M, Bheemreddy A, Anjaria M, Momeni K, Saleh S, Forrest GF. Differential Corticospinal Excitability and Cortical Functional Connectivity Modulation by Spinal Cord Transcutaneous Stimulation-based Motor Training versus Motor Training alone in Able-bodied and SCI participants: A Multiple Case Study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083293 DOI: 10.1109/embc40787.2023.10340957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Spinal cord transcutaneous stimulation (scTS) has shown its potential for boosting motor, sensory, and autonomic function recovery after a spinal cord injury. Despite the demonstrated benefits, little is known about the exact neuromodulatory mechanisms triggered by scTS and the cortex involvement in the beneficial effects observed. Here, we examine the effects of scTS-based motor training and motor training alone on sensorimotor cortical functional connectivity and corticospinal excitability in able-bodied and SCI participants.Clinical Relevance- The results show preliminary evidence of differential cortical involvement and modulation by scTS-based motor training in uninjured and spinal-cord injured individuals. A better understanding of scTS mechanisms of action could help optimize the intervention design and potentiate its benefits.
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26
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Germann M, Baker SN. Testing a Novel Wearable Device for Motor Recovery of the Elbow Extensor Triceps Brachii in Chronic Spinal Cord Injury. eNeuro 2023; 10:ENEURO.0077-23.2023. [PMID: 37460228 PMCID: PMC10399611 DOI: 10.1523/eneuro.0077-23.2023] [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: 02/22/2023] [Revised: 05/24/2023] [Accepted: 05/30/2023] [Indexed: 07/29/2023] Open
Abstract
After corticospinal tract damage, reticulospinal connections to motoneurons strengthen preferentially to flexor muscles. This could contribute to the disproportionately poor recovery of extensors often seen after spinal cord injury (SCI) and stroke. In this study, we paired electrical stimulation over the triceps muscle with auditory clicks, using a wearable device to deliver stimuli over a prolonged period of time. Healthy human volunteers wore the stimulation device for ∼6 h and a variety of electrophysiological assessments were used to measure changes in triceps motor output. In contrast to previous results in the biceps muscle, paired stimulation: (1) did not increase the StartReact effect; (2) did not decrease the suppression of responses to transcranial magnetic brain stimulation (TMS) following a loud sound; (3) did not enhance muscle responses elicited by a TMS coil oriented to induce anterior-posterior current. In a second study, chronic cervical SCI survivors wore the stimulation device for ∼4 h every day for four weeks; this was compared with a four-week period without wearing the device. Functional and electrophysiological assessments were repeated at week 0, week 4, and week 8. No significant changes were observed in electrophysiological assessments after paired stimulation. Functional measurements such as maximal force and variability and speed of trajectories made during a planar reaching task also remained unchanged. Our results suggest that the triceps muscle shows less potential for plasticity than biceps; pairing clicks with muscle stimulation does not seem beneficial in enhancing triceps recovery after SCI.
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Affiliation(s)
- Maria Germann
- Institute of Biosciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
| | - Stuart N Baker
- Institute of Biosciences, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE2 4HH, United Kingdom
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27
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Sharma P, Panta T, Ugiliweneza B, Bert RJ, Gerasimenko Y, Forrest G, Harkema S. Multi-Site Spinal Cord Transcutaneous Stimulation Facilitates Upper Limb Sensory and Motor Recovery in Severe Cervical Spinal Cord Injury: A Case Study. J Clin Med 2023; 12:4416. [PMID: 37445450 DOI: 10.3390/jcm12134416] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/19/2023] [Accepted: 06/24/2023] [Indexed: 07/15/2023] Open
Abstract
Individuals with cervical spinal cord injury (SCI) rank regaining arm and hand function as their top rehabilitation priority post-injury. Cervical spinal cord transcutaneous stimulation (scTS) combined with activity-based recovery training (ABRT) is known to effectively facilitate upper extremity sensorimotor recovery in individuals with residual arm and hand function post SCI. However, scTS effectiveness in facilitating upper extremity recovery in individuals with severe SCI with minimal to no sensory and motor preservation below injury level remains largely unknown. We herein introduced a multimodal neuro-rehabilitative approach involving scTS targeting systematically identified various spinal segments combined with ABRT. We hypothesized that multi-site scTS combined with ABRT will effectively neuromodulate the spinal networks, resulting in improved integration of ascending and descending neural information required for sensory and motor recovery in individuals with severe cervical SCI. To test the hypothesis, a 53-year-old male (C2, AIS A, 8 years post-injury) received 60 ABRT sessions combined with continuous multi-site scTS. Post-training assessments revealed improved activation of previously paralyzed upper extremity muscles and sensory improvements over the dorsal and volar aspects of the hand. Most likely, altered spinal cord excitability and improved muscle activation and sensations resulted in observed sensorimotor recovery. However, despite promising neurophysiological evidence pertaining to motor re-activation, we did not observe visually appreciable functional recovery on obtained upper extremity motor assessments.
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Affiliation(s)
- Pawan Sharma
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA
| | - Tudor Panta
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA
- Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY 40202, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA
- Department of Health Management and Systems Science, University of Louisville, Louisville, KY 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
| | - Robert J Bert
- Department of Radiology, University of Louisville, Louisville, KY 40202, USA
| | - Yury Gerasimenko
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA
- Department of Physiology, University of Louisville, Louisville, KY 40292, USA
- Pavlov Institute of Physiology, Russian Academy of Sciences, 199034 Saint Petersburg, Russia
| | - Gail Forrest
- Department of Physical Medicine & Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ 07052, USA
- Kessler Foundation, Newark, NJ 07052, USA
| | - Susan Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40202, USA
- Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY 40202, USA
- Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA
- Department of Bioengineering, University of Louisville, Louisville, KY 40202, USA
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Pelc M, Vilimkova Kahankova R, Blaszczyszyn M, Mikolajewski D, Konieczny M, Khoma V, Bara G, Zygarlicki J, Martinek R, Gupta MK, Gorzelanczyk EJ, Pawłowski M, Czapiga B, Zygarlicka M, Kawala-Sterniuk A. Initial study on an expert system for spine diseases screening using inertial measurement unit. Sci Rep 2023; 13:10440. [PMID: 37369726 PMCID: PMC10300108 DOI: 10.1038/s41598-023-36798-7] [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: 11/24/2022] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
In recent times, widely understood spine diseases have advanced to one of the most urgetn problems where quick diagnosis and treatment are needed. To diagnose its specifics (e.g. to decide whether this is a scoliosis or sagittal imbalance) and assess its extend, various kind of imaging diagnostic methods (such as X-Ray, CT, MRI scan or ST) are used. However, despite their common use, some may be regarded as (to a level) invasive methods and there are cases where there are contraindications to using them. Besides, which is even more of a problem, these are very expensive methods and whilst their use for pure diagnostic purposes is absolutely valid, then due to their cost, they cannot rather be considered as tools which would be equally valid for bad posture screening programs purposes. This paper provides an initial evaluation of the alternative approach to the spine diseases diagnostic/screening using inertial measurement unit and we propose policy-based computing as the core for the inference systems. Although the methodology presented herein is potentially applicable to a variety of spine diseases, in the nearest future we will focus specifically on sagittal imbalance detection.
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Affiliation(s)
- Mariusz Pelc
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland.
- School of Computing and Mathematical Sciences, University of Greenwich, London, SE10 9LS, UK.
| | - Radana Vilimkova Kahankova
- Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava-Poruba, Czech Republic
| | - Monika Blaszczyszyn
- Faculty of Physical Education and Physiotherapy, Opole University of Technology, 45-758, Opole, Poland
| | - Dariusz Mikolajewski
- Faculty of Computer Science, Kazimierz Wielki University, 85-064, Bydgoszcz, Poland
| | - Mariusz Konieczny
- Faculty of Physical Education and Physiotherapy, Opole University of Technology, 45-758, Opole, Poland
| | - Volodymir Khoma
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland
- Lviv Polytechnic National University, Institute of Computer Technologies, Automation and Metrology, Lviv, Ukraine
| | - Gregor Bara
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Jaroslaw Zygarlicki
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland
| | - Radek Martinek
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland
- Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, Ostrava-Poruba, Czech Republic
| | - Munish K Gupta
- Faculty of Mechanical Engineering, Opole University of Technology, 45-271, Opole, Poland
- Department of Mechanical Engineering, Graphic Era University, Dehradun, India
| | - Edward Jacek Gorzelanczyk
- Faculty of Philosophy, Kazimierz Wielki University, Bydgoszcz, 85-092, Poland
- Faculty of Mathematics and Computer Science, Adam Mickiewicz University in Poznan, Poznan, 61-614, Poland
- Department of Theoretical Basis of Biomedical Sciences and Medical Informatics, Nicolaus Copernicus University, Collegium Medicum, 85-067, Bydgoszcz, Poland
- The Society for the Substitution Treatment of Addiction "Medically Assisted Recovery", 85-791, Bydgoszcz, Poland
- Psychiatric Department of Children and Adolescents Psychiatric Center in Warta, 98-290, Warta, Poland
| | - Mateusz Pawłowski
- Faculty of Health Sciences, Wroclaw Medical University, Wrocław, Poland
- Department of Neurosurgery, "Vital Medic" Hospital, Kluczbork, Poland
| | - Bogdan Czapiga
- Department of Neurosurgery, 4th Military Hospital in Wrocław, Wrocław, Poland
| | - Malgorzata Zygarlicka
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland
| | - Aleksandra Kawala-Sterniuk
- Faculty of Electrical Engineering, Automatic Control and Informatics, Opole University of Technology, 45-758, Opole, Poland.
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Jo HJ, Kizziar E, Sangari S, Chen D, Kessler A, Kim K, Anschel A, Heinemann AW, Mensh BD, Awadalla S, Lieber RL, Oudega M, Perez MA. Multisite Hebbian Plasticity Restores Function in Humans with Spinal Cord Injury. Ann Neurol 2023; 93:1198-1213. [PMID: 36843340 PMCID: PMC10268028 DOI: 10.1002/ana.26622] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 12/29/2022] [Accepted: 02/06/2023] [Indexed: 02/28/2023]
Abstract
OBJECTIVE Spinal cord injury (SCI) damages synaptic connections between corticospinal axons and motoneurons of many muscles, resulting in devastating paralysis. We hypothesized that strengthening corticospinal-motoneuronal synapses at multiple spinal cord levels through Hebbian plasticity (i.e., "neurons that fire together, wire together") promotes recovery of leg and arm function. METHODS Twenty participants with chronic SCI were randomly assigned to receive 20 sessions of Hebbian or sham stimulation targeting corticospinal-motoneuronal synapses of multiple leg muscles followed by exercise. Based on the results from this study, in a follow-up prospective study, 11 more participants received 40 sessions of Hebbian stimulation targeting corticospinal-motoneuronal synapses of multiple arm and leg muscles followed by exercise. During Hebbian stimulation sessions, 180 paired pulses elicited corticospinal action potentials by magnetic (motor cortex) and/or electrical (thoracic spine) stimulation allowing volleys to arrive at the spinal cord 1-2 milliseconds before motoneurons were activated retrogradely via bilateral electrical stimulation (brachial plexus, ulnar, femoral, and common peroneal nerves) for biceps brachii, first dorsal interosseous, quadriceps femoris, and tibialis anterior muscles as needed. RESULTS We found in our randomized study that participants receiving Hebbian stimulation improved their walking speed and corticospinal function to a greater extent than individuals receiving sham stimulation. In agreement, prospective study participants improved their grasping and walking, corticospinal function, and quality of life metrics, exhibiting greater improvements with more sessions that persisted 9-month post-therapy. INTERPRETATION Our findings suggest that multisite Hebbian stimulation, informed by the physiology of the corticospinal system, represents an effective strategy to promote functional recovery following SCI. ANN NEUROL 2023;93:1198-1213.
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Affiliation(s)
- Hang Jin Jo
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Ethan Kizziar
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
| | - Sina Sangari
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - David Chen
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Allison Kessler
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Ki Kim
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Alan Anschel
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Allen W. Heinemann
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
| | - Brett D. Mensh
- Janelia Research Campus, Howard Hughes Medical Institute, Ashburn, Virginia, USA
| | - Saria Awadalla
- Division of Epidemiology & Biostatistics, University of Illinois at Chicago, Chicago, USA
| | - Richard L. Lieber
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
- Edward Jr. Hines VA Hospital, Chicago, USA
| | - Martin Oudega
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
- Edward Jr. Hines VA Hospital, Chicago, USA
| | - Monica A. Perez
- Shirley Ryan AbilityLab, Chicago, USA
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, USA
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, USA
- Edward Jr. Hines VA Hospital, Chicago, USA
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Effects of trunk neuromuscular electrical stimulation on the motor circuits of able-bodied individuals. Exp Brain Res 2023; 241:979-990. [PMID: 36918420 PMCID: PMC10082097 DOI: 10.1007/s00221-023-06585-x] [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: 08/20/2022] [Accepted: 02/25/2023] [Indexed: 03/16/2023]
Abstract
Upper- and lower-limb neuromuscular electrical stimulation (NMES) is known to modulate the excitability of the neural motor circuits. However, it remains unclear whether short-duration trunk muscle NMES could achieve similar neuromodulation effects. We assessed motor evoked potentials (MEPs) elicited through transcranial magnetic stimulation of the primary motor cortex representation of the trunk extensor muscles to evaluate corticospinal excitability. Moreover, cervicomedullary motor evoked potentials (CMEPs) were assessed through cervicomedullary junction magnetic stimulation to evaluate subcortical excitability. Twelve able-bodied individuals participated in the MEP study, and another twelve in the CMEP study. During the interventions, NMES was applied bilaterally to activate the erector spinae muscle and produce intermittent contractions (20 s ON/20 s OFF) for a total of 20 min while participants remained seated. Assessments were performed: (i) before; (ii) during (in brief periods when NMES was OFF); and (iii) immediately after the interventions to compare MEP or CMEP excitability. Our results showed that MEP responses were not affected by trunk NMES, while CMEP responses were facilitated for approximately 8 min during the intervention, and returned to baseline before the end of the 20 min stimulating period. Our findings therefore suggest that short-duration NMES of the trunk extensor muscles likely does not affect the corticospinal excitability, but it has a potential to facilitate subcortical neural circuits immediately after starting the intervention. These findings indicate that short-duration application of NEMS may be helpful in rehabilitation to enhance neuromodulation of the trunk subcortical neural motor circuits.
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García-Alén L, Kumru H, Castillo-Escario Y, Benito-Penalva J, Medina-Casanovas J, Gerasimenko YP, Edgerton VR, García-Alías G, Vidal J. Transcutaneous Cervical Spinal Cord Stimulation Combined with Robotic Exoskeleton Rehabilitation for the Upper Limbs in Subjects with Cervical SCI: Clinical Trial. Biomedicines 2023; 11:589. [PMID: 36831125 PMCID: PMC9953486 DOI: 10.3390/biomedicines11020589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 02/06/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
(1) Background: Restoring arm and hand function is a priority for individuals with cervical spinal cord injury (cSCI) for independence and quality of life. Transcutaneous spinal cord stimulation (tSCS) promotes the upper extremity (UE) motor function when applied at the cervical region. The aim of the study was to determine the effects of cervical tSCS, combined with an exoskeleton, on motor strength and functionality of UE in subjects with cSCI. (2) Methods: twenty-two subjects participated in the randomized mix of parallel-group and crossover clinical trial, consisting of an intervention group (n = 15; tSCS exoskeleton) and a control group (n = 14; exoskeleton). The assessment was carried out at baseline, after the last session, and two weeks after the last session. We assessed graded redefined assessment of strength, sensibility, and prehension (GRASSP), box and block test (BBT), spinal cord independence measure III (SCIM-III), maximal voluntary contraction (MVC), ASIA impairment scale (AIS), and WhoQol-Bref; (3) Results: GRASSP, BBT, SCIM III, cylindrical grip force and AIS motor score showed significant improvement in both groups (p ≤ 0.05), however, it was significantly higher in the intervention group than the control group for GRASSP strength, and GRASSP prehension ability (p ≤ 0.05); (4) Conclusion: our findings show potential advantages of the combination of cervical tSCS with an exoskeleton to optimize the outcome for UE.
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Affiliation(s)
- Loreto García-Alén
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Universitat Autónoma de Barcelona, 08193 Barcelona, Spain
| | - Hatice Kumru
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Universitat Autónoma de Barcelona, 08193 Barcelona, Spain
- Fundació Institut d’Investigació en Ciéncies de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
| | - Yolanda Castillo-Escario
- Institute for Bioengineering of Catalonia, Barcelona Institute of Science and Technology, 08028 Barcelona, Spain
- Department of Automatic Control, Universitat Politécnica de Catalunya-Barcelona Tech (UPC), 08028 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Bioingeniería, Biomateriales y Nanomedicina, 28029 Madrid, Spain
| | - Jesús Benito-Penalva
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Universitat Autónoma de Barcelona, 08193 Barcelona, Spain
- Fundació Institut d’Investigació en Ciéncies de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
| | - Josep Medina-Casanovas
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Universitat Autónoma de Barcelona, 08193 Barcelona, Spain
- Fundació Institut d’Investigació en Ciéncies de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
| | - Yury P. Gerasimenko
- Pavlov Institute of Physiology, St. Petersburg 199034, Russia
- Department of Physiology and Biophysics, University of Louisville, Louisville, KY 40292, USA
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY 40292, USA
| | - Victor Reggie Edgerton
- Rancho Research Institute, Los Amigos National Rehabilitation Center, Downey, CA 90242, USA
| | - Guillermo García-Alías
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Departament de Biologia Cel·lular, Fisiologia i Immunologia & Insititute of Neuroscience, Universitat Autónoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Joan Vidal
- Fundación Institut Guttmann, Institut Universitari de Neurorrehabilitació Adscrit a la UAB, 08916 Badalona, Spain
- Universitat Autónoma de Barcelona, 08193 Barcelona, Spain
- Fundació Institut d’Investigació en Ciéncies de la Salut Germans Trias i Pujol, 08916 Badalona, Spain
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First Use of Non-Invasive Spinal Cord Stimulation in Motor Rehabilitation of Children with Spinal Muscular Atrophy. Life (Basel) 2023; 13:life13020449. [PMID: 36836806 PMCID: PMC9966619 DOI: 10.3390/life13020449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/21/2023] [Accepted: 02/03/2023] [Indexed: 02/09/2023] Open
Abstract
Spinal muscular atrophy (SMA) is characterized by the degeneration of spinal alpha motorneurons. Nusinersen demonstrated good efficacy in the early disease phases. The feasibility of transcutaneous spinal cord stimulation (tSCS) in motor rehabilitation of patients with spinal cord injury has been demonstrated. We hypothesize that tSCS may activate intact and restored by nusinersen motorneurons and slow down the decline in motor activity, and may contribute to the development of motor skills in children with SMA. A case series is presented. Five children (6-13 years old) with SMA type II or III participated in the study. They were treated with nusinersen for ~2 years. Application of tSCS was carried out during physical therapy for 30-40 min per day in the course of 10-14 days. Outcome measures were goniometry of joints with contracture, forced vital capacity (FVC), RULM and HFMSE scales. The participants tolerated the stimulation well. The reduction of the contracture was ≥5 deg. RULM and HFMSE increased by ~1-2 points. Predicted FVC increased by 1-7% in three participants. Each participant expanded their range of active movements and/or learned new motor skills. Spinal cord stimulation may be an effective rehabilitation method in patients treated with nusinersen. More research is needed.
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Angeli CA, Gerasimenko Y. Combined cervical transcutaneous with lumbosacral epidural stimulation improves voluntary control of stepping movements in spinal cord injured individuals. Front Bioeng Biotechnol 2023; 11:1073716. [PMID: 36815892 PMCID: PMC9932494 DOI: 10.3389/fbioe.2023.1073716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction: Lumbosacral spinal cord neuromodulation has shown the ability to restore voluntary control and stepping in individuals with chronic spinal cord injury. Methods: We combined cervical transcutaneous and lumbar epidural stimulation to explore the brain-spinal connectomes and their influence in spinal excitability and interlimb coupling. Four individuals with a prior implanted lumbosacral spinal cord epidural stimulator participated in the study. We assessed lower extremity muscle activity and kinematics during intentional stepping in both non-weight bearing and weight-bearing environments. Results: Our results showed an inhibition of motor evoked potentials generated by spinal cord epidural stimulation when cervical transcutaneous stimulation is applied. In contrast, when intentional stepping is performed in a non-weight bearing setting, range of motion, motor output amplitude, and coordination are improved when cervical transcutaneous and lumbar epidural stimulations are combined. Similarly, with both stimulations applied, coordination is improved and motor output variability is decreased when intentional stepping is performed on a treadmill with body weight support. Discussion: Combined transcutaneous cervical and epidural lumbar stimulation demonstrated an improvement of voluntary control of stepping in individuals with chronic motor complete paralysis. The immediate functional improvement promoted by the combination of cervical and lumbar stimulation adds to the body of evidence for increasing spinal excitability and improvement of function that is possible in individuals with chronic paralysis.
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Affiliation(s)
- Claudia A. Angeli
- Bioengineering Department, J. B. Speed School of Engineering, University of Louisville, Louisville, KY, United States
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Frazier Rehabilitation Institute, University of Louisville Health, Louisville, KY, United States
| | - Yury Gerasimenko
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
- Department of Physiology, University of Louisville, Louisville, KY, United States
- Pavlov Institute of Physiology, St. Petersburg, Russia
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Rehman MU, Sneed D, Sutor TW, Hoenig H, Gorgey AS. Optimization of Transspinal Stimulation Applications for Motor Recovery after Spinal Cord Injury: Scoping Review. J Clin Med 2023; 12:854. [PMID: 36769503 PMCID: PMC9917510 DOI: 10.3390/jcm12030854] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 01/25/2023] Open
Abstract
Spinal cord injury (SCI) is a debilitating condition that can significantly affect an individual's life, causing paralysis, autonomic dysreflexia, and chronic pain. Transspinal stimulation (TSS) is a non-invasive form of neuromodulation that activates the underlying neural circuitries of the spinal cord. Application of TSS can be performed through multiple stimulation protocols, which may vary in the electrodes' size or position as well as stimulation parameters, and which may influence the response of motor functions to the stimulation. Due to the novelty of TSS, it is beneficial to summarize the available evidence to identify the range of parameters that may provide the best outcomes for motor response. The PubMed and Google Scholar databases were searched for studies examining the effects of TSS on limb motor function. A literature search yielded 34 studies for analysis, in which electrode placement and stimulation parameters varied considerably. The stimulation protocols from each study and their impact on limb motor function were summarized. Electrode placement was variable based on the targeted limb. Studies for the upper limbs targeted the cervical enlargement with anatomical placement of the cathode over the cervical vertebral region. In lower-limb studies, the cathode(s) were placed over the thoracic and lumbar vertebral regions, to target the lumbar enlargement. The effects of carrier frequency were inconclusive across the studies. Multisite cathodal placements yielded favorable motor response results compared to single-site placement. This review briefly summarized the current mechanistic evidence of the effect of TSS on motor response after SCI. Our findings indicate that optimization of stimulation parameters will require future randomized controlled studies to independently assess the effects of different stimulation parameters under controlled circumstances.
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Affiliation(s)
- Muhammad Uzair Rehman
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, USA
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Dustin Sneed
- Department of Physical Medicine and Rehabilitation, School of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Tommy W. Sutor
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, USA
| | - Helen Hoenig
- Physical Medicine & Rehabilitation Service, Durham VA Health Care System, Durham, NC 27705, USA
- Geriatrics Division, Department of Medicine, Duke University, Durham, NC 27710, USA
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA 23249, USA
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA 23284, USA
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Singh G, Lucas K, Keller A, Martin R, Behrman A, Vissarionov S, Gerasimenko YP. Transcutaneous Spinal Stimulation From Adults to Children: A Review. Top Spinal Cord Inj Rehabil 2022; 29:16-32. [PMID: 36819932 PMCID: PMC9936896 DOI: 10.46292/sci21-00084] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Neuromodulation via spinal stimulation is a promising therapy that can augment the neuromuscular capacity for voluntary movements, standing, stepping, and posture in individuals with spinal cord injury (SCI). The spinal locomotor-related neuronal network known as a central pattern generator (CPG) can generate a stepping-like motor output in the absence of movement-related afferent signals from the limbs. Using epidural stimulation (EP) in conjunction with activity-based locomotor training (ABLT), the neural circuits can be neuromodulated to facilitate the recovery of locomotor functions in persons with SCI. Recently, transcutaneous spinal stimulation (scTS) has been developed as a noninvasive alternative to EP. Early studies of scTS at thoracolumbar, coccygeal, and cervical regions have demonstrated its effectiveness in producing voluntary leg movements, posture control, and independent standing and improving upper extremity function in adults with chronic SCI. In pediatric studies, the technology of spinal neuromodulation is not yet widespread. There are a limited number of publications reporting on the use of scTS in children and adolescents with either cerebral palsy, spina bifida, or SCI.
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Affiliation(s)
- Goutam Singh
- Kosair Charities School of Physical Therapy, Spalding University, Louisville, Kentucky
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
| | - Kathryn Lucas
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Anastasia Keller
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Rebecca Martin
- International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at Kennedy Krieger Institute, Baltimore, Maryland
- Department of Physical Medicine and Rehabilitation, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrea Behrman
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Sergey Vissarionov
- Turner Scientific Research Institute for Children's Orthopedics, St. Petersburg, Russia
| | - Yury P Gerasimenko
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, Kentucky
- Department of Physiology, University of Louisville, Louisville, Kentucky
- Pavlov Institute of Physiology Russian Academy of Sciences, St. Petersburg, Russia
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Moshonkina TR, Zharova EN, Ananev SS, Shandybina ND, Vershinina EA, Lyakhovetskii VA, Grishin AA, Shlyakhto EV, Gerasimenko YP. A New Technology for Recovery of Locomotion in Patients after a Stroke. DOKL BIOCHEM BIOPHYS 2022; 507:353-356. [PMID: 36787001 DOI: 10.1134/s1607672922340087] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/03/2022] [Accepted: 10/09/2022] [Indexed: 02/15/2023]
Abstract
Neural networks in the spinal cord can generate the walking pattern and control posture in the absence of supraspinal influences. A technology using transcutaneous electrical spinal cord stimulation (tSCS) was created. During walking, tSCS activated spinal locomotor networks, as well as leg flexor/extensor motor pools in the swing/stance phases, respectively. It was assumed that the use of this technology in subjects with locomotion disorders would improve walking. Patients with hemiparesis were studied 3-11 months after stroke, the duration of the course was 2 weeks. Patients of the main and control groups received standard therapy and rehabilitation using the technology; in the control group, sham tSCS was used. After the course, minimal clinically important differences in walking parameters were achieved in the main group, in contrast to the control group. The developed technology is an effective means of restoring walking in patients with hemiparesis.
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Affiliation(s)
- T R Moshonkina
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia.
| | - E N Zharova
- Almazov National Medical Research Centre, St. Petersburg, Russia
| | - S S Ananev
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - N D Shandybina
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - E A Vershinina
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - V A Lyakhovetskii
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - A A Grishin
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
| | - E V Shlyakhto
- Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Y P Gerasimenko
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg, Russia
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Shackleton C, Hodgkiss D, Samejima S, Miller T, Perez MA, Nightingale TE, Sachdeva R, Krassioukov AV. When the whole is greater than the sum of its parts: a scoping review of activity-based therapy paired with spinal cord stimulation following spinal cord injury. J Neurophysiol 2022; 128:1292-1306. [PMID: 36222423 DOI: 10.1152/jn.00367.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/06/2022] [Indexed: 11/22/2022] Open
Abstract
Spinal cord injury (SCI) results in both motor and autonomic impairments, which can negatively affect independence and quality of life and increase morbidity and mortality. Despite emerging evidence supporting the benefits of activity-based training and spinal cord stimulation as two distinct interventions for sensorimotor and autonomic recovery, the combined effects of these modalities are currently uncertain. This scoping review evaluated the effectiveness of paired interventions (exercise + spinal neuromodulation) for improving sensorimotor and autonomic functions in individuals with SCI. Four electronic databases were searched for peer-reviewed manuscripts (Medline, Embase, CINAHL, and EI-compedex Engineering Village) and data were independently extracted by two reviewers using pre-established extraction tables. A total of 15 studies representing 79 participants were included in the review, of which 73% were conducted within the past 5 years. Only two of the studies were randomized controlled studies, while the other 13 studies were case or case-series designs. Compared with activity-based training alone, spinal cord stimulation combined with activity-based training improved walking and voluntary muscle activation, and augmented improvements in lower urinary tract, bowel, resting metabolic rate, peak oxygen consumption, and thermoregulatory function. Spinal neuromodulation in combination with use-dependent therapies may provide greater neurorecovery and induce long-term benefits for both motor and autonomic function beyond the capacity of traditional activity-based therapies. However, evidence for combinational approaches is limited and there is no consensus for outcome measures or optimal protocol parameters, including stimulation settings. Future large-scale randomized trials into paired interventions are warranted to further investigate these preliminary findings.
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Affiliation(s)
- Claire Shackleton
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Hodgkiss
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Soshi Samejima
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tiev Miller
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica A Perez
- Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Shirley Ryan Ability Laboratory, Chicago, Illinois
- Edward Hines Jr. VA Hospital, Chicago, Illinois
| | - Thomas E Nightingale
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Spinal Cord Program, GF Strong Rehabilitation Centre, University of British Columbia, Vancouver, British Columbia, Canada
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Teaford M, Keller K, Merfeld DM. The contribution of interoceptive signals to spatial orientation: A mini-review. Neurosci Biobehav Rev 2022; 143:104943. [DOI: 10.1016/j.neubiorev.2022.104943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/15/2022] [Accepted: 10/31/2022] [Indexed: 11/07/2022]
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Flett S, Garcia J, Cowley KC. Spinal electrical stimulation to improve sympathetic autonomic functions needed for movement and exercise after spinal cord injury: a scoping clinical review. J Neurophysiol 2022; 128:649-670. [PMID: 35894427 PMCID: PMC9668071 DOI: 10.1152/jn.00205.2022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/19/2022] [Accepted: 07/24/2022] [Indexed: 11/22/2022] Open
Abstract
Spinal cord injury (SCI) results in sensory, motor, and autonomic dysfunction. Obesity, cardiovascular disease, and metabolic disease are highly prevalent after SCI. Although inadequate voluntary activation of skeletal muscle contributes, it is absent or inadequate activation of thoracic spinal sympathetic neural circuitry and suboptimal activation of homeostatic (cardiovascular and temperature) and metabolic support systems that truly limits exercise capacity, particularly for those with cervical SCI. Thus, when electrical spinal cord stimulation (SCS) studies aimed at improving motor functions began mentioning effects on exercise-related autonomic functions, a potential new area of clinical application appeared. To survey this new area of potential benefit, we performed a systematic scoping review of clinical SCS studies involving these spinally mediated autonomic functions. Nineteen studies were included, 8 used transcutaneous and 11 used epidural SCS. Improvements in blood pressure regulation at rest or in response to orthostatic challenge were investigated most systematically, whereas reports of improved temperature regulation, whole body metabolism, and peak exercise performance were mainly anecdotal. Effective stimulation locations and parameters varied between studies, suggesting multiple stimulation parameters and rostrocaudal spinal locations may influence the same sympathetic function. Brainstem and spinal neural mechanisms providing excitatory drive to sympathetic neurons that activate homeostatic and metabolic tissues that provide support for movement and exercise and their integration with locomotor neural circuitry are discussed. A unifying conceptual framework for the integrated neural control of locomotor and sympathetic function is presented which may inform future research needed to take full advantage of SCS for improving these spinally mediated autonomic functions.
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Affiliation(s)
- Sarah Flett
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Juanita Garcia
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristine C Cowley
- Department of Physiology and Pathophysiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Gorgey AS, Gouda JJ. Single Lead Epidural Spinal Cord Stimulation Targeted Trunk Control and Standing in Complete Paraplegia. J Clin Med 2022; 11:jcm11175120. [PMID: 36079048 PMCID: PMC9457264 DOI: 10.3390/jcm11175120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/22/2022] [Accepted: 08/26/2022] [Indexed: 11/16/2022] Open
Abstract
A 25-year-old male with T3 complete AIS A was implanted with percutaneous spinal cord epidural stimulation (scES; eight contacts each) leads and a Medtronic Prime advance internal pulse generator. The two leads were placed at the midline level to cover the region of the T11–T12 vertebrae. Five days after implantation, X-ray showed complete migration of the left lead outside the epidural space. Two weeks after implantation, reprogramming of the single right lead (20 Hz and 240 µs) after setting the cathode at 0 and the anode at 3 resulted in target activation of the abdominal muscles and allowed for the immediate restoration of trunk control during a seated position, even with upper extremity perturbation. This was followed by achieving immediate standing after setting the single lead at −3 for the cathode and +6 for the anode using stimulation configurations of 20 Hz and 240 µs. The results were confirmed with electromyography (EMG) of the rectus abdominus and lower extremity muscles. Targeted stimulation of the lumbosacral segment using a single lead with a midline approach immediately restored the trunk control and standing in a person with complete paraplegia.
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Affiliation(s)
- Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire VAMC, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA
- Department of Physical Medicine & Rehabilitation, Virginia Commonwealth University, Richmond, VA 23298, USA
- Correspondence: ; Tel.: +1-804-675-5000 (ext. 3386)
| | - Jan J. Gouda
- Neurosurgery Department, Louran Hospital, Alexandria 5451110, Egypt
- Department of Surgery, Wright State University, Dayton, OH 45435, USA
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Samejima S, Henderson R, Pradarelli J, Mondello SE, Moritz CT. Activity-dependent plasticity and spinal cord stimulation for motor recovery following spinal cord injury. Exp Neurol 2022; 357:114178. [PMID: 35878817 DOI: 10.1016/j.expneurol.2022.114178] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/22/2022] [Accepted: 07/16/2022] [Indexed: 02/07/2023]
Abstract
Spinal cord injuries lead to permanent physical impairment despite most often being anatomically incomplete disruptions of the spinal cord. Remaining connections between the brain and spinal cord create the potential for inducing neural plasticity to improve sensorimotor function, even many years after injury. This narrative review provides an overview of the current evidence for spontaneous motor recovery, activity-dependent plasticity, and interventions for restoring motor control to residual brain and spinal cord networks via spinal cord stimulation. In addition to open-loop spinal cord stimulation to promote long-term neuroplasticity, we also review a more targeted approach: closed-loop stimulation. Lastly, we review mechanisms of spinal cord neuromodulation to promote sensorimotor recovery, with the goal of advancing the field of rehabilitation for physical impairments following spinal cord injury.
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Affiliation(s)
- Soshi Samejima
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Richard Henderson
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jared Pradarelli
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Sarah E Mondello
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Chet T Moritz
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; Center for Neurotechnology, Seattle, WA, USA; Department of Physiology and Biophysics, University of Washington, Seattle, WA, USA.
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Novel Noninvasive Spinal Neuromodulation Strategy Facilitates Recovery of Stepping after Motor Complete Paraplegia. J Clin Med 2022; 11:jcm11133670. [PMID: 35806954 PMCID: PMC9267673 DOI: 10.3390/jcm11133670] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/03/2022] [Accepted: 06/16/2022] [Indexed: 02/04/2023] Open
Abstract
It has been suggested that neuroplasticity-promoting neuromodulation can restore sensory-motor pathways after spinal cord injury (SCI), reactivating the dormant locomotor neuronal circuitry. We introduce a neuro-rehabilitative approach that leverages locomotor training with multi-segmental spinal cord transcutaneous electrical stimulation (scTS). We hypothesized that scTS neuromodulates spinal networks, complementing the neuroplastic effects of locomotor training, result in a functional progression toward recovery of locomotion. We conducted a case-study to test this approach on a 27-year-old male classified as AIS A with chronic SCI. The training regimen included task-driven non-weight-bearing training (1 month) followed by weight-bearing training (2 months). Training was paired with multi-level continuous and phase-dependent scTS targeting function-specific motor pools. Results suggest a convergence of cross-lesional networks, improving kinematics during voluntary non-weight-bearing locomotor-like stepping. After weight-bearing training, coordination during stepping improved, suggesting an important role of afferent feedback in further improvement of voluntary control and reorganization of the sensory-motor brain-spinal connectome.
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43
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de Freitas RM, Capogrosso M, Nomura T, Milosevic M. Optimizing sensory fiber activation during cervical transcutaneous spinal stimulation using different electrode configurations: A computational analysis. Artif Organs 2022; 46:2015-2026. [PMID: 35642297 DOI: 10.1111/aor.14323] [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: 02/25/2022] [Revised: 04/21/2022] [Accepted: 05/18/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cervical transcutaneous spinal cord stimulation (tSCS) is a rehabilitation tool which has been used to promote upper-limb motor recovery after spinal cord injury. Importantly, optimizing sensory fiber activation at specific spinal segments could enable activity-dependent neuromodulation during rehabilitation. METHODS An anatomically realistic cervical tSCS computational model was used to analyze the activation of α-motor and Aα-sensory fibers at C7 and C8 spinal segments using nine cathode electrode configurations. Specifically, the cathode was simulated at three vertebral level positions: C6, C7, and T1; and in three sizes: 5.0 x 5.0, 3.5 x 3.5; and 2.5 x 2.5 cm2 , while the anode was on the anterior neck. Finite element method was used to estimate the electric potential distribution along α-motor and Aα-sensory fibers, and computational models were applied to simulate the fiber membrane dynamics during tSCS. The minimum stimulation intensity necessary to activate the fibers (activation threshold) was estimated and compared across cathode configurations in an effort to optimize sensory fiber activation. RESULTS Our results showed that nerve fibers at both C7 and C8 spinal segments were recruited at lower stimulation intensities when the cathode was positioned over the C7 or T1 vertebra compared with the C6 position. Sensory fibers were activated at lower stimulation intensities using smaller electrodes, which could also affect the degree of nerve fiber activation across different positions. Importantly, Aα-sensory fibers were consistently recruited before α-motor fibers. CONCLUSIONS These results imply that cathode positioning could help optimize preferential activation of hand muscles during cervical tSCS.
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Affiliation(s)
- Roberto M de Freitas
- Graduate School of Engineering Science, Department of Mechanical Science and Bioengineering, Osaka University, Japan
| | - Marco Capogrosso
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, USA.,Rehab and Neural Engineering Labs, University of Pittsburgh, Pittsburgh, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, USA
| | - Taishin Nomura
- Graduate School of Engineering Science, Department of Mechanical Science and Bioengineering, Osaka University, Japan
| | - Matija Milosevic
- Graduate School of Engineering Science, Department of Mechanical Science and Bioengineering, Osaka University, Japan
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44
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de Freitas RM, Capogrosso M, Nomura T, Milosevic M. Preferential activation of proprioceptive and cutaneous sensory fibers compared to motor fibers during cervical transcutaneous spinal cord stimulation: A computational study. J Neural Eng 2022; 19. [PMID: 35472720 DOI: 10.1088/1741-2552/ac6a7c] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/25/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Cervical transcutaneous spinal cord stimulation (tSCS) is a promising technology that can support motor function recovery of upper-limbs after spinal cord injury. Its efficacy may depend on the ability to recruit sensory afferents, conveying excitatory inputs onto motoneurons. Therefore, understanding its physiological mechanisms is critical to accelerate its development towards clinical applications. In this study, we used an anatomically realistic cervical tSCS computational model to compare α-motor, Aα-sensory, and Aβ-sensory fiber activation thresholds and activation sites. APPROACH We developed a 3D geometry of the cervical body and tSCS electrodes with a cathode centred at the C7 spinous process and an anode placed over the anterior neck. The geometrical model was used to estimate the electric potential distributions along motor and sensory fiber trajectories at the C7 spinal level using a finite element method. We implemented dedicated motor and sensory fiber models to simulate the α-motor and Aα-sensory fibers using 12, 16, and 20 µm diameter fibers, and Aβ-sensory fibers using 6, 9, and 12 µm diameter fibers. We estimated nerve fiber activation thresholds and sites for a 2 ms monophasic stimulating pulse and compared them across the fiber groups. MAIN RESULTS Our results showed lower activation thresholds of Aα- and Aβ-sensory fibers compared with α-motor fibers, suggesting preferential sensory fiber activation. We also found no differences between activation thresholds of Aα-sensory and large Aβ-sensory fibers, implying their co-activation. The activation sites were located at the dorsal and ventral root levels. SIGNIFICANCE Using a realistic computational model, we demonstrated preferential activation of dorsal root Aα- and Aβ-sensory fibers compared with ventral root α-motor fibers during cervical tSCS. These findings suggest high proprioceptive and cutaneous contributions to neural activations during cervical tSCS, which inform the underlying mechanisms of upper-limb functional motor recovery.
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Affiliation(s)
- Roberto M de Freitas
- Graduate School of Engineering Science, Osaka University, 1-3 Machikaneyama-cho, Toyonaka, 560-8531, JAPAN
| | - Marco Capogrosso
- University of Pittsburgh, 3520, Fifth Av., Pittsburgh, Pennsylvania, 15261, UNITED STATES
| | - Taishin Nomura
- Department of Mechanical Science and Bioengineering, Osaka University, Machikaneyama 1-3, Toyonaka City, Osaka 560- 8531, Toyonaka, 5608531, JAPAN
| | - Matija Milosevic
- Graduate School of Engineering Science, Osaka University, 1-3 Machikaneyama-cho, J520, Toyonaka, Osaka, 560-8531, JAPAN
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45
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Rahman MA, Tharu NS, Gustin SM, Zheng YP, Alam M. Trans-Spinal Electrical Stimulation Therapy for Functional Rehabilitation after Spinal Cord Injury: Review. J Clin Med 2022; 11:1550. [PMID: 35329875 PMCID: PMC8954138 DOI: 10.3390/jcm11061550] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023] Open
Abstract
Spinal cord injury (SCI) is one of the most debilitating injuries in the world. Complications after SCI, such as respiratory issues, bowel/bladder incontinency, pressure ulcers, autonomic dysreflexia, spasticity, pain, etc., lead to immense suffering, a remarkable reduction in life expectancy, and even premature death. Traditional rehabilitations for people with SCI are often insignificant or ineffective due to the severity and complexity of the injury. However, the recent development of noninvasive electrical neuromodulation treatments to the spinal cord have shed a ray of hope for these individuals to regain some of their lost functions, a reduction in secondary complications, and an improvement in their life quality. For this review, 250 articles were screened and about 150 were included to summarize the two most promising noninvasive spinal cord electrical stimulation methods of SCI rehabilitation treatment, namely, trans-spinal direct current stimulation (tsDCS) and trans-spinal pulsed current stimulation (tsPCS). Both treatments have demonstrated good success in not only improving the sensorimotor function, but also autonomic functions. Due to the noninvasive nature and lower costs of these treatments, in the coming years, we expect these treatments to be integrated into regular rehabilitation therapies worldwide.
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Affiliation(s)
- Md. Akhlasur Rahman
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
- Centre for the Rehabilitation of the Paralysed (CRP), Savar Union 1343, Bangladesh
| | - Niraj Singh Tharu
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
| | - Sylvia M. Gustin
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia;
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW 2031, Australia
| | - Yong-Ping Zheng
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
| | - Monzurul Alam
- Department of Biomedical Engineering, The Hong Kong Polytechnic University, Hong Kong, China; (M.A.R.); (N.S.T.); (Y.-P.Z.)
- NeuroRecovery Research Hub, School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia;
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, NSW 2031, Australia
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Effect of Cervical Transcutaneous Spinal Cord Stimulation on Sensorimotor Cortical Activity during Upper-Limb Movements in Healthy Individuals. J Clin Med 2022; 11:jcm11041043. [PMID: 35207314 PMCID: PMC8878243 DOI: 10.3390/jcm11041043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 12/14/2022] Open
Abstract
Transcutaneous spinal cord stimulation (tSCS) can improve upper-limb motor function after spinal cord injury. A number of studies have attempted to deduce the corticospinal mechanisms which are modulated following tSCS, with many relying on transcranial magnetic stimulation to provide measures of corticospinal excitability. Other metrics, such as cortical oscillations, may provide an alternative and complementary perspective on the physiological effect of tSCS. Hence, the present study recorded EEG from 30 healthy volunteers to investigate if and how cortical oscillatory dynamics are altered by 10 min of continuous cervical tSCS. Participants performed repetitive upper-limb movements and resting-state tasks while tSCS was delivered to the posterior side of the neck as EEG was recorded simultaneously. The intensity of tSCS was tailored to each participant based on their maximum tolerance (mean: 50 ± 20 mA). A control session was conducted without tSCS. Changes to sensorimotor cortical activity during movement were quantified in terms of event-related (de)synchronisation (ERD/ERS). Our analysis revealed that, on a group level, there was no consistency in terms of the direction of ERD modulation during tSCS, nor was there a dose-effect between tSCS and ERD/ERS. Resting-state oscillatory power was compared before and after tSCS but no statistically significant difference was found in terms of alpha peak frequency or alpha power. However, participants who received the highest stimulation intensities had significantly weakened ERD/ERS (10% ERS) compared to when tSCS was not applied (25% ERD; p = 0.016), suggestive of cortical inhibition. Overall, our results demonstrated that a single 10 min session of tSCS delivered to the cervical region of the spine was not sufficient to induce consistent changes in sensorimotor cortical activity among the entire cohort. However, under high intensities there may be an inhibitory effect at the cortical level. Future work should investigate, with a larger sample size, the effect of session duration and tSCS intensity on cortical oscillations.
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Barss TS, Parhizi B, Porter J, Mushahwar VK. Neural Substrates of Transcutaneous Spinal Cord Stimulation: Neuromodulation across Multiple Segments of the Spinal Cord. J Clin Med 2022; 11:639. [PMID: 35160091 PMCID: PMC8836636 DOI: 10.3390/jcm11030639] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 02/01/2023] Open
Abstract
Transcutaneous spinal cord stimulation (tSCS) has the potential to promote improved sensorimotor rehabilitation by modulating the circuitry of the spinal cord non-invasively. Little is currently known about how cervical or lumbar tSCS influences the excitability of spinal and corticospinal networks, or whether the synergistic effects of multi-segmental tSCS occur between remote segments of the spinal cord. The aim of this review is to describe the emergence and development of tSCS as a novel method to modulate the spinal cord, while highlighting the effectiveness of tSCS in improving sensorimotor recovery after spinal cord injury. This review underscores the ability of single-site tSCS to alter excitability across multiple segments of the spinal cord, while multiple sites of tSCS converge to facilitate spinal reflex and corticospinal networks. Finally, the potential and current limitations for engaging cervical and lumbar spinal cord networks through tSCS to enhance the effectiveness of rehabilitation interventions are discussed. Further mechanistic work is needed in order to optimize targeted rehabilitation strategies and improve clinical outcomes.
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Affiliation(s)
- Trevor S. Barss
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2R3, Canada; (T.S.B.); (B.P.)
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Behdad Parhizi
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2R3, Canada; (T.S.B.); (B.P.)
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Jane Porter
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Vivian K. Mushahwar
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB T6G 2R3, Canada; (T.S.B.); (B.P.)
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of Alberta, Edmonton, AB T6G 2R3, Canada;
- Sensory Motor Adaptive Rehabilitation Technology (SMART) Network, University of Alberta, Edmonton, AB T6G 2R3, Canada
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Burns M, Solinsky R. Toward rebalancing blood pressure instability after spinal cord injury with spinal cord electrical stimulation: A mini review and critique of the evolving literature. Auton Neurosci 2022; 237:102905. [PMID: 34800845 PMCID: PMC9280330 DOI: 10.1016/j.autneu.2021.102905] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/07/2021] [Accepted: 11/06/2021] [Indexed: 01/03/2023]
Abstract
High-level spinal cord injury commonly leads to blood pressure instability. This manifests clinically as orthostatic hypotension (OH), where blood pressure can drop to the point of loss of consciousness, and autonomic dysreflexia (AD), where systolic blood pressure can climb to over 300 mmHg in response to an unperceived noxious stimulus. These blood pressure fluctuations can occur multiple times a day, contributing to increased vessel shear stress and heightened risk of cardiovascular disease. The pathophysiology of both of these conditions is rooted in impairments in regulation of spinal cord sympathetic preganglionic neurons, which control blood pressure by mediating vascular resistance and catecholamine release. Recently, spinal cord electrical stimulation has provided evidence that it may modulate these blood pressure imbalances. Early proposed mechanisms suggest activation of spinal cord dorsal horn neurons that ultimately act upon the sympathetic preganglionic neuronal pathways. For OH, spinal cord stimulation likely induces local activation of these neurons to generate baseline sympathetic tone and accompanying vasoconstriction. The mechanisms for spinal stimulation regulating AD are less clear, though some suggest it activates inhibitory circuits to dampen the overactive sympathetic response. While questions remain, spinal cord electrical stimulation is an intriguing new modality that may restore blood pressure regulation following spinal cord injury.
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Affiliation(s)
- Madeleine Burns
- Boston University School of Medicine, Graduate Medical Sciences
| | - Ryan Solinsky
- Spaulding Rehabilitation Hospital,Department of Physical Medicine & Rehabilitation, Harvard Medical School,Spaulding Research Institute
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Sutor TW, Ghatas MP, Goetz LL, Lavis TD, Gorgey AS. Exoskeleton Training and Trans-Spinal Stimulation for Physical Activity Enhancement After Spinal Cord Injury (EXTra-SCI): An Exploratory Study. FRONTIERS IN REHABILITATION SCIENCES 2022; 2:789422. [PMID: 35169770 PMCID: PMC8842517 DOI: 10.3389/fresc.2021.789422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022]
Abstract
After spinal cord injury (SCI) physical activity levels decrease drastically, leading to numerous secondary health complications. Exoskeleton-assisted walking (EAW) may be one way to improve physical activity for adults with SCI and potentially alleviate secondary health complications. The effects of EAW may be limited, however, since exoskeletons induce passive movement for users who cannot volitionally contribute to walking. Trans-spinal stimulation (TSS) has shown the potential to enable those with even the most severe SCI to actively contribute to movements during EAW. To explore the effects of EAW training on improving secondary health complications in persons with SCI, participants with chronic (n = 8) were enrolled in an EAW program 2-3 times per week for 12 weeks. Anthropometrics (seated and supine waist and abdominal circumferences (WC and AC), body composition assessment (dual exposure x-ray absorptiometry-derived body fat percent, lean mass and total mass for the total body, legs, and trunk), and peak oxygen consumption (VO2 during a 6-minute walk test [6MWT]) were assessed before and after 12 weeks of EAW training. A subset of participants (n = 3) completed EAW training with concurrent TSS, and neuromuscular activity of locomotor muscles was assessed during a 10-m walk test (10MWT) with and without TSS following 12 weeks of EAW training. Upon completion of 12 weeks of training, reductions from baseline (BL) were found in seated WC (-2.2%, P = 0.036), seated AC (-2.9%, P = 0.05), and supine AC (-3.9%, P = 0.017). Percent fat was also reduced from BL for the total body (-1.4%, P = 0.018), leg (-1.3%, P = 0.018), and trunk (-2%, P = 0.036) regions. No effects were found for peak VO2. The addition of TSS for three individuals yielded individualized responses but generally increased knee extensor activity during EAW. Two of three participants who received TSS were also able to initiate more steps without additional assistance from the exoskeleton during a 10MWT. In summary, 12 weeks of EAW training significantly attenuated markers of obesity relevant to cardiometabolic health in eight men with chronic SCI. Changes in VO2 and neuromuscular activity with vs. without TSS were highly individualized and yielded no overall group effects.
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Affiliation(s)
- Tommy W. Sutor
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, United States
| | - Mina P. Ghatas
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, United States
| | - Lance L. Goetz
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, United States
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Timothy D. Lavis
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, United States
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Ashraf S. Gorgey
- Spinal Cord Injury and Disorders Center, Hunter Holmes McGuire Veteran Affairs Medical Center, Richmond, VA, United States
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
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Flores Á, López-Santos D, García-Alías G. When Spinal Neuromodulation Meets Sensorimotor Rehabilitation: Lessons Learned From Animal Models to Regain Manual Dexterity After a Spinal Cord Injury. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:755963. [PMID: 36188826 PMCID: PMC9397786 DOI: 10.3389/fresc.2021.755963] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/16/2021] [Indexed: 12/22/2022]
Abstract
Electrical neuromodulation has strongly hit the foundations of spinal cord injury and repair. Clinical and experimental studies have demonstrated the ability to neuromodulate and engage spinal cord circuits to recover volitional motor functions lost after the injury. Although the science and technology behind electrical neuromodulation has attracted much of the attention, it cannot be obviated that electrical stimulation must be applied concomitantly to sensorimotor rehabilitation, and one would be very difficult to understand without the other, as both need to be finely tuned to efficiently execute movements. The present review explores the difficulties faced by experimental and clinical neuroscientists when attempting to neuromodulate and rehabilitate manual dexterity in spinal cord injured subjects. From a translational point of view, we will describe the major rehabilitation interventions employed in animal research to promote recovery of forelimb motor function. On the other hand, we will outline some of the state-of-the-art findings when applying electrical neuromodulation to the spinal cord in animal models and human patients, highlighting how evidences from lumbar stimulation are paving the path to cervical neuromodulation.
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Affiliation(s)
- África Flores
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - Diego López-Santos
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
| | - Guillermo García-Alías
- Department of Cell Biology, Physiology and Immunology, Institute of Neuroscience, Universitat Autònoma de Barcelona and Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Bellaterra, Spain
- Institut Guttmann de Neurorehabilitació, Badalona, Spain
- *Correspondence: Guillermo García-Alías
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