To assess safety and mobility outcomes utilizing the Indego powered exoskeleton in indoor and outdoor walking conditions with individuals previously diagnosed with a spinal cord injury (SCI).
We ...conducted a multicenter prospective observational cohort study in outpatient clinics associated with 5 rehabilitation hospitals. A convenience sample of nonambulatory individuals with SCI (
= 32) completed an 8-week training protocol consisting of walking training 3 times per week utilizing the Indego powered exoskeleton in indoor and outdoor conditions. Participants were also trained in donning/doffing the exoskeleton during each session. Safety measures such as adverse events (AEs) were monitored and reported. Time and independence with donning/doffing the exoskeleton as well as walking outcomes to include the 10-meter walk test (10MWT), 6-minute walk test (6MWT), Timed Up & Go test (TUG), and 600-meter walk test were evaluated from midpoint to final evaluations.
All 32 participants completed the training protocol with limited device-related AEs, which resulted in no interruption in training. The majority of participants in this trial were able to don and doff the Indego independently. Final walking speed ranged from 0.19 to 0.55 m/s. Final average indoor and outdoor walking speeds among all participants were 0.37 m/s (
= 0.08, 0.09, respectively), after 8 weeks of training. Significant (
< .05) improvements were noted between midpoint and final gait speeds in both indoor and outdoor conditions. Average walking endurance also improved among participants after training.
The Indego was shown to be safe for providing upright mobility to 32 individuals with SCIs who were nonambulatory. Improvements in speed and independence were noted with walking in indoor and outdoor conditions as well as with donning/doffing the exoskeleton.
Recovery of the upper extremity (UE) and hand function is considered the highest priority for people with tetraplegia, because these functions closely integrate with their activities of daily living. ...Spinal cord transcutaneous stimulation (scTS) has great potential to facilitate functional restoration of paralyzed limbs by neuro-modulating the excitability of the spinal network. Recently, this approach has been demonstrated effective in improving UE function in people with motor complete and incomplete cervical SCI. However, the research thus far is limited by the lack of a comprehensive assessment of functional improvement and neurological recovery throughout the intervention. The goal of this study was to investigate whether scTS can also facilitate UE functional restoration in an individual with motor and sensory complete tetraplegia. A 38-year-old male with a C5 level, ASIA Impairment Scale-A SCI (15 years post-injury, left hand dominant pre- and post-injury), received 18 sessions (60 minutes/session) of scTS combined with task-specific hand training over the course of 8 weeks. The total score of the Graded Redefined Assessment of Strength, Sensibility, and Prehension significantly improved from 72/232 to 96/232 at post-intervention, and maintained ranging from 82/232 to 86/232 during the three months follow-up without any further treatment. The bilateral handgrip force improved by 283.4% (left) and 30.7% (right), respectively at post-intervention. These strength gains were sustained at 233.5% -250% (left) and 11.5%-73.1% (right) during the follow-up evaluation visits. Neuromuscular Recovery Scale demonstrated dramatic and long-lasting improvements following the completion of the intervention. Changes of spinal motor evoked potentials from pre- to post-intervention indicated an increased level of spinal network excitability. The present data offer preliminary evidence that the novel scTS intervention combined with hand training can enhance UE functional use in people with motor and sensory complete SCI.
To evaluate the relationship and redundancy between gait speeds measured by the 10 Meter Walk Test (10MWT) and 6 Minute Walk Test (6MWT) after motor incomplete spinal cord injury (iSCI). To identify ...gait speed thresholds supporting functional ambulation as measured with the Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI).
Prospective observational cohort.
Seven outpatient rehabilitation centers from the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN).
249 NRN patients with American Spinal Injury Association Impairment Scale (AIS) level C (n = 20), D (n = 179) and (n = 50) iSCI not AIS evaluated, from February 2008 through April 2011.
Locomotor training using body weight support and walking on a treadmill, overground and home/community practice.
10MWT and 6MWT collected at enrollment, approximately every 20 sessions, and upon discharge.
The 10MWT and 6MWT speeds were highly correlated and the 10MWT speeds were generally faster. However, the predicted 6MWT gait speed from the 10MWT, revealed increasing error with increased gait speed. Regression lines remained significantly different from lines of agreement, when the group was divided into fast (≥0.44 m/s) and slow walkers (<0.44 m/s). Significant differences between 6MWT and 10MWT gait speeds were observed across SCI-FAI walking mobility categories (Wilcoxon sign rank test p<.001), and mean speed thresholds for limited community ambulation differed for each measure. The smallest real difference for the 6MWT and 10MWT, as well as the minimally clinically important difference (MCID) values, were also distinct for the two tests.
While the speeds were correlated between the 6MWT and 10MWT, redundancy in the tests using predictive modeling was not observed. Different speed thresholds and separate MCIDs were defined for community ambulation for each test.
Short-chain fatty acids (SCFAs), primarily acetate, propionate, and butyrate, are metabolites formed by gut microbiota from complex dietary carbohydrates. Butyrate and acetate were reported to ...protect against diet-induced obesity without causing hypophagia, while propionate was shown to reduce food intake. However, the underlying mechanisms for these effects are unclear. It was suggested that SCFAs may regulate gut hormones via their endogenous receptors Free fatty acid receptors 2 (FFAR2) and 3 (FFAR3), but direct evidence is lacking. We examined the effects of SCFA administration in mice, and show that butyrate, propionate, and acetate all protected against diet-induced obesity and insulin resistance. Butyrate and propionate, but not acetate, induce gut hormones and reduce food intake. As FFAR3 is the common receptor activated by butyrate and propionate, we examined these effects in FFAR3-deficient mice. The effects of butyrate and propionate on body weight and food intake are independent of FFAR3. In addition, FFAR3 plays a minor role in butyrate stimulation of Glucagon-like peptide-1, and is not required for butyrate- and propionate-dependent induction of Glucose-dependent insulinotropic peptide. Finally, FFAR3-deficient mice show normal body weight and glucose homeostasis. Stimulation of gut hormones and food intake inhibition by butyrate and propionate may represent a novel mechanism by which gut microbiota regulates host metabolism. These effects are largely intact in FFAR3-deficient mice, indicating additional mediators are required for these beneficial effects.
Surface electromyography (sEMG) is a widely used technology in rehabilitation research and provides quantifiable information on the myoelectric output of a muscle. In this perspective, we discuss the ...barriers which have restricted the wide-spread use of sEMG in clinical rehabilitation of individuals with spinal cord injury (SCI). One of the major obstacles is integrating the time-consuming aspects of sEMG in the already demanding schedule of physical therapists, occupational therapists, and other clinicians. From the clinicians' perspective, the lack of confidence to use sEMG technology is also apparent due to their limited exposure to the sEMG technology and possibly limited mathematical foundation through educational and professional curricula. Several technical challenges include the limited technology-transfer of ever-evolving knowledge from sEMG research into the off-the-shelf EMG systems, lack of demand from the clinicians for systems with advanced features, lack of user-friendly intuitive interfaces, and the need for a multidisciplinary approach for accurate handling and interpretation of data. We also discuss the challenges in the application and interpretation of sEMG that are specific to SCI, which are characterized by non-standardized approaches in recording and interpretation of EMGs due to the physiological and structural state of the spinal cord. Addressing the current barriers will require a collaborative, interdisciplinary, and unified approach. The most relevant steps could include enhancing user-experience for students pursuing clinical education through revised curricula through sEMG-based case studies/projects, hands-on involvement in the research, and formation of a common platform for clinicians and technicians for self-education and knowledge share.
There is a growing interest in non-invasive stimulation interventions as treatment strategies to improve functional outcomes and recovery after spinal cord injury (SCI). Repetitive transcranial ...magnetic stimulation (rTMS) is a neuromodulatory intervention which has the potential to reinforce the residual spinal and supraspinal pathways and induce plasticity. Recent reviews have highlighted the therapeutic potential and the beneficial effects of rTMS on motor function, spasticity, and corticospinal excitability modulation in SCI individuals. For this scoping review, we focus on the stimulation parameters used in 20 rTMS protocols. We extracted the rTMS parameters from 16 published rTMS studies involving SCI individuals and were able to infer preliminary associations between specific parameters and the effects observed. Future investigations will need to consider timing, intervention duration and dosage (in terms of number of sessions and number of pulses) that may depend on the stage, the level, and the severity of the injury. There is a need for more real vs. sham rTMS studies, reporting similar designs with sufficient information for replication, to achieve a significant level of evidence regarding the use of rTMS in SCI.
To determine the impact of long-term, body weight-supported locomotor training after chronic, incomplete spinal cord injury (SCI), and to estimate the health care costs related to lost recovery ...potential and preventable secondary complications that may have occurred because of visit limits imposed by insurers.
Prospective observational cohort with longitudinal follow-up.
Eight outpatient rehabilitation centers that participate in the Christopher & Dana Reeve Foundation NeuroRecovery Network (NRN).
Individuals with motor incomplete chronic SCI (American Spinal Injury Association Impairment Scale C or D; N=69; 0.1-45y after SCI) who completed at least 120 NRN physical therapy sessions.
Manually assisted locomotor training (LT) in a body weight-supported treadmill environment, overground standing and stepping activities, and community integration tasks.
International Standards for Neurological Classification of Spinal Cord Injury motor and sensory scores, orthostatic hypotension, bowel/bladder/sexual function, Spinal Cord Injury Functional Ambulation Inventory (SCI-FAI), Berg Balance Scale, Modified Functional Reach, 10-m walk test, and 6-minute walk test. Longitudinal outcome measure collection occurred every 20 treatments and at 6- to 12-month follow-up after discharge from therapy.
Significant improvement occurred for upper and lower motor strength, functional activities, psychological arousal, sensation of bowel movement, and SCI-FAI community ambulation. Extended training enabled minimal detectable changes at 60, 80, 100, and 120 sessions. After detectable change occurred, it was sustained through 120 sessions and continued 6 to 12 months after treatment.
Delivering at least 120 sessions of LT improves recovery from incomplete chronic SCI. Because walking reduces rehospitalization, LT delivered beyond the average 20-session insurance limit can reduce rehospitalizations and long-term health costs.
Background
It has been demonstrated that in young and healthy individuals, there is a strong association between the amplitude of EEG-derived motor activity-related cortical potential or EEG spectral ...power (ESP) and voluntary muscle force. This association suggests that the motor-related ESP may serve as an index of central nervous system function in controlling voluntary muscle activation Therefore, it may potentially be used as an objective marker to track changes in functional neuroplasticity due to neurological disorders, aging, and following rehabilitation therapies. To this end, the relationship between the band-specific ESP—combined spectral power of EEG oscillatory and aperiodic (noise) components—and voluntary elbow flexion (EF) force has been analyzed in elder and young individuals.
Methods
20 young (22.6 ± 0.87 year) and 28 elderly (74.79 ± 1.37 year) participants performed EF contractions at 20%, 50%, and 80% of maximum voluntary contraction (MVC) while high-density EEG signals were recorded. Both the absolute and relative ESPs were computed for the EEG frequency bands of interest.
Results
The MVC force generated by the elderly was foreseeably lower than that of the young participants. Compared to young, the elderly cohort’s (1) total ESP was significantly lower for the high (80% MVC) force task; (2) relative ESP in beta band was significantly elevated for the low and moderate (20% MVC and 50% MVC) force tasks; (3) absolute ESP failed to have a positive trend with force for EEG frequency bands of interest; and (4) beta-band relative ESP did not exhibit a significant decrease with increasing force levels.
Conclusions
As opposed to young subjects, the beta-band relative ESP in elderly did not significantly decrease with increasing EF force values. This observation suggests the use of beta-band relative ESP as a potential biomarker for age-related motor control degeneration.
To determine the effect of transcutaneous spinal stimulation (TSS) on an implanted intrathecal baclofen (ITB) pump in persons with traumatic spinal cord injury (SCI).
Prospective clinical trial.
Five ...individuals with chronic traumatic SCI, >18 years of age, and an anteriorly implanted Medtronic SynchroMed™ II ITB pump delivery system.
Transcutaneous spinal stimulation trials with cathode at T11/12, with pump interrogation before, during and after stimulation.
There was no evidence of any effect of the TSS in regards to disruption of the ITB pump delivery mechanism. Communication interference with the interrogator to the pump occurred often during stimulation for log transmission most likely secondary to the electromagnetic interference from the stimulation. One individual had elevated blood pressure at the end of the trial, suspected to be unrelated to the spinal stimulation.
Based upon this pilot study, further TSS studies including persons with an implanted Medtronic SynchroMed™ II ITB pump can be considered when stimulating at the low thoracic spine, although communication with the programmer during the stimulation may be affected.
High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) remains a promising strategy for neurorehabilitation. The stimulation intensity (SI) influences the aftereffects observed. Here, ...we examined whether single sessions of a 15 Hz rTMS protocol, administered at suprathreshold SI, can be safely administered to able-bodied (AB) individuals. Six right-handed men were included in this pilot study. HF-rTMS was delivered over the right M1, in 10 trains of 75 biphasic stimuli at 15 Hz, at 105-120% of the individual resting motor threshold (RMT). To assess safety, electromyography (EMG) was monitored to control for signs of spread of excitation and brief EMG burst (BEB) after stimulation. Additionally, TMS side effects questionnaires and the numeric rating scale (NRS) were administered during each session. We assessed corticospinal excitability (CSE) and motor performance changes with measures of resting (rMEP) and active (aMEP) motor evoked potential and grip strength and box and blocks test (BBT) scores, respectively. Overall, the sessions were tolerated and feasible without any pain development. However, EMG analysis during 15 Hz rTMS administration revealed increased BEB frequency with SI. Statistical models revealed an increase of CSE at rest (rMEP) but not during active muscle contraction (aMEP). No linear relationship was observed between 15 Hz rTMS SI and rMEP increase. No significant changes were highlighted for motor performance measures. Although feasible and tolerable by the AB individuals tested, the results demonstrate that when administered at suprathreshold intensities (≥ 105% RMT) the 15 Hz rTMS protocol reveals signs of persistent excitation, suggesting that safety precautions and close monitoring of participants should be performed when testing such combinations of high-intensity and high-frequency stimulation protocols. The results also give insight into the nonlinear existent relationship between the SI and HF-rTMS effects on CSE.
The results of this pilot study show the effects of a therapeutically promising 15 Hz repetitive transcranial magnetic stimulation (rTMS) protocol, administered at different suprathreshold intensities in able-bodied individuals. Although tolerable and feasible with a neuromodulatory potential, 15 Hz rTMS might result in persistent excitability that needs to be closely monitored if administered at suprathreshold stimulation intensity. These results reaffirm the importance of feasibility studies, especially in translational animal-to-human research.
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