Epidural Spinal Stimulation to Improve Bladder, Bowel, and Sexual Function in Individuals With Spinal Cord Injuries: A Framework for Clinical Research

While some recent studies that apply epidural spinal cord stimulation (SCS) have demonstrated a breakthrough in improvement of the health and quality of the life of persons with spinal cord injury (SCI), the numbers of people who have received SCS are small. This is in sharp contrast to the thousands of persons worldwide living with SCI who have no practical recourse or hope of recovery of lost functions. Thus, the vision is to understand the full potential of this new intervention and to determine if it is safe and effective in a larger cohort, and if it is scalable so that it can be made available to all those who might benefit. To achieve this vision, the National Institute of Biomedical Imaging and Bioengineering called for and organized a consortium of multiple stakeholder groups: foundations addressing paralysis, federal and public agencies, industrial partners, academicians, and researchers, all interested in the same goal. Based on input from consortium participants, we have reasoned that a first step is to define a scalable SCS approach that is effective in restoring lost autonomic physiology, specifically bladder, bowel, and sexual function. These functions are most critical for improving the quality of life of persons living with SCI. This report outlines a framework for conducting the research needed to define such an effective SCS procedure that might seek Food and Drug Administration approval and be implemented at the population level.

Dynamic and kinematic strategies for head movement control

This paper describes our analysis of the complex head-neck system using a combination of experimental and modeling approaches. Dynamical analysis of head movements and EMG activation elicited by perturbation of trunk position has examined functional contributions of biomechanically and neurally generated forces in lumped systems with greatly simplified kinematics. This has revealed that visual and voluntary control of neck muscles and the dynamic and static vestibulocollic and cervicocollic reflexes preferentially govern head-neck system state in different frequency domains. It also documents redundant control, which allows the system to compensate for lesions and creates a potential for substantial variability within and between subjects. Kinematic studies have indicated the existence of reciprocal and co-contraction strategies for voluntary force generation, of a vestibulocollic strategy for stabilizing the head during body perturbations and of at least two strategies for voluntary head tracking. Each strategy appears to be executed by a specific muscle synergy that is presumably optimized to efficiently meet the demands of the task.

Predicting vestibular, proprioceptive, and biomechanical control strategies in normal and pathological head movements

Little is known of the functionality of the vestibulocollic reflex (VCR) and cervico-collic reflex (CCR) during head and neck movements caused by perturbations of the trunk. Previously, we formulated mathematical expressions for these neck reflexes and incorporated them into a model of horizontal plane head movements. The formalism of this neuromechanical model allowed us to examine separately the main components of head movement control. In the present study, we examine selected parameters within the main components of the model, and associate variations of these parameters with disease processes affecting head and neck movements, such as loss of sensory input or modification in central or motor function. Our simulations led us to several conclusions. First, the probable use of the VCR and CCR in yaw plane head movements is to tune the head response. In the time domain, they diminish natural head oscillations (head wobble) related to head mechanics. Equivalently, in the frequency domain, they reduce the amplitude of head wobble (resonances) around 2 Hz. Second, our simulations suggest that the VCR is about ten times stronger than the CCR in normal humans. Moreover, this disproportion is associated with only very minor contributions from the CCR in yaw. Third, head oscillations (or instability) can be generated by mechanical or neural changes in the head and neck system. Finally, readjustments of central nervous system dynamic operations could provide mechanisms to compensate for sensory and motor dysfunction caused by disease.

Context-specific short-term adaptation of the phase of the vestibulo-ocular reflex

The phase of the angular vestibulo-ocular reflex (VOR) is subject to adaptive control. We had previously found that adapting the phase of the VOR also produced changes in drift on eccentric gaze-holding, implying a change in the time constant of the velocity-to-position neural integrator. Here we attempted to dissociate changes in gaze-holding drift from changes in the phase of the VOR. In normal human subjects, for 2 h, we alternated 5 min of VOR phase adaptation (sinusoids, 0.2 Hz) with 5 min of making saccades in the light with the head stationary. Afterwards, changes in VOR phase were the same (32% of requested) as those obtained with 1 h of phase adaptation alone, but changes in drift following saccades were much smaller than those found after phase adaptation alone (0.8 degrees/s compared with 5 degrees/s). When measuring drift after VOR steps, however, the changes were closer to those found after phase adaptation alone (3.8 degrees/s). To test the relationship between gaze-holding drift after VOR steps and adaptive changes in VOR phase, we alternated sinusoidal VOR phase adaptation with normal VOR steps in the light. In this paradigm, the adaptive change in VOR phase was about the same as with phase-adaptation alone (35%), but there was now little drift after saccades (1.9 degrees/s) or after VOR steps (0.7 degrees/s). We conclude that the state of the velocity-to-position neural integrator can be altered selectively and rapidly depending upon the task required. Such context-specific adaptation is advantageous, because it allows adjustment of the phase of the VOR without degrading the ability to hold eccentric fixation.

Effect of BL-10 (tianzhu), BL-11 (dazhu) and GB-34 (yanglinquan) acuplaster for prevention of vomiting after strabismus surgery in children

BACKGROUND

Stimulation of P6 (Neiguan) acupoint can prevent nausea and vomiting in adults. However, there is no antiemetic effect in children undergoing strabismus surgery. The effect of P6 may act only on hollow organs; in contrast, BL-10 (Tianzhu), BL-11 (Dazhu) and GB-34 (Yanglinquan) are more related to the meridians of the eye. Therefore these three more relevant acupoints, BL-10, BL-11 and GB-34 were stimulated to evaluate the antiemetic effect in children undergoing strabismus surgery.

METHODS

Sixty-five children, ASA physical status I, between 3 and 14 years of age, were randomly divided into two groups as follows: placebo group (n = 31) and acuplaster group (n = 34). Bilateral acupressure using the Vital Point Needleless Acuplaster (Koa, Japan) was applied to BL-10, BL-11 and GB-34 points the night before surgery. Anesthesia was induced and maintained with halothane and nitrous oxide in oxygen. Postoperative emesis was assessed at early (at PACU) and late (at ward) phases, and was recorded by an investigator blind to the treatment characteristics.

RESULTS

In the early emesis phase, the incidence of vomiting was 35.5% for placebo group, compared with 14.7% for acuplaster group. In the late emesis phase, acuplaster patients had a significantly lower incidence of vomiting (23.5% vs. 58.1% in placebo patients, p < 0.05). The overall postoperative vomiting incidence in the acuplaster patients in a 24 h period which was significantly decreased was 29.4% as opposed 64.5% in the placebo group (p < 0.05).

CONCLUSIONS

The results demonstrated that prophylactic use of bilateral noninvasive acuplaster on the BL-10, BL-11, and GB-34 acupoints significantly reduces vomiting after strabismus correction. The mechanism may be dispersal of these three acupoints, thus diminishing the parasympathetic stimulation resulting from surgical traction of eye muscles.

A dynamical model for reflex activated head movements in the horizontal plane

We present a controls systems model of horizontal-plane head movements during perturbations of the trunk, which for the first time interfaces a model of the human head with neural feedback controllers representing the vestibulocollic (VCR) and the cervicocollic (CCR) reflexes. This model is homeomorphic such that model structure and parameters are drawn directly from anthropomorphic, biomechanical and physiological studies. Using control theory we analyzed the system model in the time and frequency domains, simulating neck movement responses to input perturbations of the trunk. Without reflex control, the head and neck system produced a second-order underdamped response with a 5.2 dB resonant peak at 2.1 Hz. Adding the CCR component to the system dampened the response by approximately 7%. Adding the VCR component dampened head oscillations by 75%. The VCR also improved low-frequency compensation by increasing the gain and phase lag, creating a phase minimum at 0.1 Hz and a phase peak at 1.1 Hz. Combining all three components (mechanics, VCR and CCR) linearly in the head and neck system reduced the amplitude of the resonant peak to 1.1 dB and increased the resonant frequency to 2.9 Hz. The closed loop results closely fit human data, and explain quantitatively the characteristic phase peak often observed.

Dynamics of directional plasticity in the human vertical vestibulo-ocular reflex

Directional plasticity of the human vestibulo-ocular reflex (VOR) was studied in 10 subjects. The adaptation paradigm coupled 0.25 Hz, 19 degrees/s vertical pitch vestibular rotations with 28 degrees/s horizontal optokinetic oscillations. Electro-oculographic recordings in the dark were taken at 0.05, 0.1, 0.25, 0.5, and 1 Hz pitch rotations before and after training and at 15-minute intervals during 0.25 Hz adaptation. Peak head velocity was kept at 19 degrees/sec for frequencies above 0.1 Hz, while constant amplitude was maintained at +/- 24 degrees for 0.05 and 0.1 Hz. In all subjects, directional training produced slow phase horizontal VOR eye movements that were not present during vertical rotations before adaptation. During the 2-hour training period, the cross-axis VOR gain at 0.25 Hz increased up to 0.16. Adaptive VOR gain was highest at the lowest frequency and reached a tuned peak at the 0.25 Hz training frequency. Cross-axis VOR phase remained around 0 degrees at higher frequencies and lagged at lower frequencies. In all subjects, the cross-axis VOR gain was diminished when subjects were exposed to 0.25 Hz pitch rotations paired with a stationary visual field. The dynamics of the vertical VOR remained constant throughout the experiment. These results are further evidence that the frequency response characteristics of adaptive cross-axis VOR gain are similar in humans and cats, while phase behavior is less complex in humans. The high adaptive gain at low frequencies implicates otolith contributions during cross-axis adaptation.