Vagus Nerve Stimulation Paired With Mobility Training in Chronic Ischemic Stroke: A Case Report.

OBJECTIVE: The purpose of this case report is to describe pairing vagus nerve stimulation (VNS) with mobility training in an individual after stroke. METHODS: A 53-year-old man with left hemiparesis 14.2 months after an ischemic stroke participated in a pilot study investigating the safety and feasibility of VNS paired with upper limb rehabilitation. In addition to upper limb impairment, the participant had impaired gait and wanted to improve his mobility. A single-subject design investigation of VNS paired with self-directed mobility training was conducted. Following the conclusion of the pilot study, the participant was instructed to complete daily sessions of self-activated VNS paired with walking or stationary biking. The 10-Meter Walk Test and timed distance (6-Minute Walk Test) were assessed at 4 baseline points and at 3 to 41 months after mobility training. RESULTS: The participant had stable baseline values and was classified as a household ambulator with a quad cane. After VNS-paired mobility training, statistically significant improvements were observed in all measures, with the greatest improvements at 9 months exceeding the minimal detectable change: self-selected gait speed from 0.34 (standard deviation [SD] = 0.01) to 0.60 meters/second, fast gait speed from 0.37 (SD = 0.03) to 0.79 meters/second, and 6-Minute Walk Test distance from 106.91 (SD = 6.38) to 179.83 meters. The participant reported increased confidence and balance when walking. No falls or adverse events were reported. CONCLUSION: The participant demonstrated improved gait speed and timed distance after VNS-paired mobility training. Randomized, blinded trials are needed to determine treatment efficacy. IMPACT: This is the first documented case of VNS-paired mobility training in an individual with chronic poststroke gait impairments. VNS paired with mobility training may improve poststroke gait impairments.

Extended effects of a wearable sensory prosthesis on gait, balance function and falls after 26 weeks of use in persons with peripheral neuropathy and high fall risk-The walk2Wellness trial.

Background: We recently reported that individuals with impaired plantar sensation and high fall risk due to sensory peripheral neuropathy (PN) improved gait and balance function following 10 weeks of use of Walkasins®, a wearable lower limb sensory prosthesis that provides directional specific mechanical tactile stimuli related to plantar pressure measurements during standing and walking (RxFunction Inc., Eden Prairie, MN, United States). Here, we report 26-week outcomes and compare pre- and in-study fall rates. We expected improvements in outcomes and reduced fall rates reported after 10 weeks of use to be sustained. Materials and methods: Participants had clinically diagnosed PN with impaired plantar sensation, high fall risk (Functional Gait Assessment, FGA score < 23) and ability to sense tactile stimuli above the ankle at the location of the device. Additional outcomes included 10 m Gait Speed, Timed Up and Go (TUG), Four-Stage Balance Test, and self-reported outcomes, including Activities-Specific Balance Confidence scale and Vestibular Disorders Activities of Daily Living Scale. Participants tracked falls using a calendar. Results: We assessed falls and self-reported outcomes from 44 individuals after 26 weeks of device use; 30 of them conducted in-person testing of clinical outcomes. Overall, improvements in clinical outcomes seen at 10 weeks of use remained sustained at 26 weeks with statistically significant increases compared to baseline seen in FGA scores (from 15.0 to 19.2), self-selected gait speed (from 0.89 to 0.97 m/s), and 4-Stage Balance Test (from 25.6 to 28.4 s), indicating a decrease in fall risk. Non-significant improvements were observed in TUG and fast gait speed. Overall, 39 falls were reported; 31 of them did not require medical treatment and four caused severe injury. Participants who reported falls over 6 months prior to the study had a 43% decrease in fall rate during the study as compared to self-report 6-month pre-study (11.8 vs. 6.7 falls/1000 patient days, respectively, p < 0.004), similar to the 46% decrease reported after 10 weeks of use. Conclusion: A wearable sensory prosthesis can improve outcomes of gait and balance function and substantially decreases incidence of falls during long-term use. The sustained long-term benefits in clinical outcomes reported here lessen the likelihood that improvements are placebo effects. Clinical trial registration: ClinicalTrials.gov, identifier #NCT03538756.

The Effects of a Wearable Sensory Prosthesis on Gait and Balance Function After 10 Weeks of Use in Persons With Peripheral Neuropathy and High Fall Risk - The walk2Wellness Trial.

BACKGROUND: Sensory peripheral neuropathy (PN) is associated with gait, balance problems and high fall risk. The walk2Wellness trial investigates effects of long-term, home-based daily use of a wearable sensory prosthesis on gait function, balance, quality of life and fall rates in PN patients. The device (Walkasins®, RxFunction Inc., MN, United States) partially substitutes lost nerve function related to plantar sensation providing directional tactile cues reflecting plantar pressure measurements during standing and walking. We tested the null hypothesis that the Functional Gait Assessment (FGA) score would remain unchanged after 10 weeks of use. METHODS: Participants had PN with lost plantar sensation, gait and balance problems, an FGA score < 23 (high fall risk), and ability to sense tactile stimuli above the ankle. Clinical outcomes included FGA, Gait Speed, Timed Up&Go (TUG) and 4-Stage Balance Test. Patient-reported outcomes included Activities-Specific Balance Confidence (ABC) scale, Vestibular Disorders Activities of Daily Living Scale, PROMIS participation and satisfaction scores, pain rating, and falls. Evaluations were performed at baseline and after 2, 6, and 10 weeks. Subjects were not made aware of changes in outcomes. No additional balance interventions were allowed. RESULTS: Forty-five participants of 52 enrolled across four sites completed in-clinic assessments. FGA scores improved from 15.0 to 19.1 (p < 0.0001), normal and fast gait speed from 0.86 m/s to 0.95 m/s (p < 0.0001) and 1.24 m/s to 1.33 m/s (p = 0.002), respectively, and TUG from 13.8 s to 12.5 s (p = 0.012). Four-Stage Balance Test did not improve. Several patient-reported outcomes were normal at baseline and remained largely unchanged. Interestingly, subjects with baseline ABC scores lower than 67% (high fall risk cut-off) increased their ABC scores (49.9% to 59.3%, p = 0.01), whereas subjects with ABC scores above 67% showed a decrease (76.6% to 71.8%, p = 0.019). Subjects who reported falls in the prior 6 months (n = 25) showed a decrease in the number of fall-risk factors (5.1 to 4.3, p = 0.023) and a decrease in fall rate (13.8 to 7.4 falls/1000 days, p = 0.014). Four pre-study non-fallers (n = 20) fell during the 10 weeks. CONCLUSION: A wearable sensory prosthesis presents a new way to treat gait and balance problems and manage falls in high fall-risk patients with PN. TRIAL REGISTRATION: ClinicalTrials.gov (#NCT03538756).

Inherent thermal regeneration performance of different MnO2 crystallographic structures for mercury removal.

Manganese oxides with different crystallographic structures were investigated for gas-phase elemental mercury removal. The inherent thermal regeneration performance and mechanism of α- and γ-MnO2 were studied. The manganese dioxides were found to possess a mercury removal efficiency of higher than 96% even after 120 min mercury exposure except for ß-MnO2 which removed much less mercury than Mn2O3. The α-MnO2 was found to have a higher recyclability of mercury capture and better durability for regeneration than γ-MnO2. During the first 1 h of exposure, α-MnO2 showed an excellent mercury capacity of 128 µg/g over 5 regeneration cycles. While for γ-MnO2, the mercury capacity of the fifth cycle was reduced to 68.74 µg/g, which is much lower than 131.42 µg/g for the first cycle. The microstructure of α-MnO2 was maintained throughout regeneration cycles due to its capability to retain lattice oxygen. In comparison, γ-MnO2 experienced reconstruction and phase transformation induced by oxygen vacancies due to lattice oxygen loss during regeneration process, leading to a degradation in mercury capture. The α-MnO2 oriented composite was found to be better developed into a regenerable catalytic sorbent for mercury removal from flue gases of coal-fired power plants.

Home-based transcranial direct current stimulation plus tracking training therapy in people with stroke: an open-label feasibility study.

BACKGROUND: Transcranial direct current stimulation (tDCS) is an effective neuromodulation adjunct to repetitive motor training in promoting motor recovery post-stroke. Finger tracking training is motor training whereby people with stroke use the impaired index finger to trace waveform-shaped lines on a monitor. Our aims were to assess the feasibility and safety of a telerehabilitation program consisting of tDCS and finger tracking training through questionnaires on ease of use, adverse symptoms, and quantitative assessments of motor function and cognition. We believe this telerehabilitation program will be safe and feasible, and may reduce patient and clinic costs. METHODS: Six participants with hemiplegia post-stroke [mean (SD) age was 61 (10) years; 3 women; mean (SD) time post-stroke was 5.5 (6.5) years] received five 20-min tDCS sessions and finger tracking training provided through telecommunication. Safety measurements included the Digit Span Forward Test for memory, a survey of symptoms, and the Box and Block test for motor function. We assessed feasibility by adherence to treatment and by a questionnaire on ease of equipment use. We reported descriptive statistics on all outcome measures. RESULTS: Participants completed all treatment sessions with no adverse events. Also, 83.33% of participants found the set-up easy, and all were comfortable with the devices. There was 100% adherence to the sessions and all recommended telerehabilitation. CONCLUSIONS: tDCS with finger tracking training delivered through telerehabilitation was safe, feasible, and has the potential to be a cost-effective home-based therapy for post-stroke motor rehabilitation. TRIAL REGISTRATION: NCT02460809 (ClinicalTrials.gov).

Silica-Silver Nanocomposites as Regenerable Sorbents for Hg0 Removal from Flue Gases.

Silica-silver nanocomposites (Ag-SBA-15) are a novel class of multifunctional materials with potential applications as sorbents, catalysts, sensors, and disinfectants. In this work, an innovative yet simple and robust method of depositing silver nanoparticles on a mesoporous silica (SBA-15) was developed. The synthesized Ag-SBA-15 was found to achieve a complete capture of Hg0 at temperatures up to 200 °C. Silver nanoparticles on the SBA-15 were shown to be the critical active sites for the capture of Hg0 by the Ag-Hg0 amalgamation mechanism. An Hg0 capture capacity as high as 13.2 mg·g-1 was achieved by Ag(10)-SBA-15, which is much higher than that achievable by existing Ag-based sorbents and comparable with that achieved by commercial activated carbon. Even after exposure to more complex simulated flue gas flow for 1 h, the Ag(10)-SBA-15 could still achieve an Hg0 removal efficiency as high as 91.6% with a Hg0 capture capacity of 457.3 µg·g-1. More importantly, the spent sorbent could be effectively regenerated and reused without noticeable performance degradation over five cycles. The excellent Hg0 removal efficiency combined with a simple synthesis procedure, strong tolerance to complex flue gas environment, great thermal stability, and outstanding regeneration capability make the Ag-SBA-15 a promising sorbent for practical applications to Hg0 capture from coal-fired flue gases.

Short-duration, high-intensity bouts of physical therapy to increase self-efficacy, confidence, and function in an individual with incomplete spinal cord injury: A case report.

High intensity and frequency of task-specific practice is required to produce functional change in individuals with neurologic conditions. Self-efficacy is an important predictor of engagement in physical activity in individuals with spinal cord injury. Combining these two rehabilitation concepts has the potential for lasting functional improvement. The purpose of this case report is to describe the management of a patient with incomplete spinal cord injury (iSCI) using a model of concentrated bouts of physical therapy with an emphasis on techniques to increase self-efficacy. The patient is a 70-yr old female who sustained C5/C6 vertebral fractures in a fall, resulting in incomplete tetraplegia. She participated in a pilot program of 1 week of intensive physical therapy every 10-12 weeks over the course of 5.5 months. Interventions included functional activities important to the patient, therapeutic exercise, and home exercise program. Confidence and self-efficacy were shaped using patient-directed discussions and active problem solving. The patient improved on all measures of gait, balance, and participation, and also reported increased confidence and self-management of her condition. A high-intensity, periodic model of care delivery combined with a capacity-building approach may be an effective method to improve confidence, motivation, and function in persons with iSCI.

Visual and Motor Recovery After "Cognitive Therapeutic Exercises" in Cortical Blindness: A Case Study.

BACKGROUND AND PURPOSE: Spontaneous visual recovery is rare after cortical blindness. While visual rehabilitation may improve performance, no visual therapy has been widely adopted, as clinical outcomes are variable and rarely translate into improvements in activities of daily living (ADLs). We explored the potential value of a novel rehabilitation approach "cognitive therapeutic exercises" for cortical blindness. CASE DESCRIPTION: The subject of this case study was 48-year-old woman with cortical blindness and tetraplegia after cardiac arrest. Prior to the intervention, she was dependent in ADLs and poorly distinguished shapes and colors after 19 months of standard visual and motor rehabilitation. Computed tomographic images soon after symptom onset demonstrated acute infarcts in both occipital cortices. INTERVENTION: The subject underwent 8 months of intensive rehabilitation with "cognitive therapeutic exercises" consisting of discrimination exercises correlating sensory and visual information. OUTCOMES: Visual fields increased; object recognition improved; it became possible to watch television; voluntary arm movements improved in accuracy and smoothness; walking improved; and ADL independence and self-reliance increased. Subtraction of neuroimaging acquired before and after rehabilitation showed that focal glucose metabolism increases bilaterally in the occipital poles. DISCUSSION: This study demonstrates feasibility of "cognitive therapeutic exercises" in an individual with cortical blindness, who experienced impressive visual and sensorimotor recovery, with marked ADL improvement, more than 2 years after ischemic cortical damage.Video Abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A173).

Potential hazards of brominated carbon sorbents for mercury emission control.

Mercury is a toxic air pollutant, emitted from the combustion of coal. Activated Carbon (AC) or other carbon sorbent (CS) injection into coal combustion flue gases can remove elemental mercury through an adsorption process. Recently, a brominated CS with biomass ash as the carbon source (Br-Ash) was developed as an alternative for costly AC-based sorbent for mercury capture. After mercury capture, these sorbents are disposed in landfill, and the stability of bromine and captured mercury is of paramount importance. The objective of this study is to determine the fate of mercury and bromine from Br-Ash and brominated AC after their service. Mercury and bromine leaching tests were conducted using the standard toxicity characteristic leaching procedure (TCLP). The mercury was found to be stable on both the Br-Ash and commercial brominated AC sorbents, while the bromine leached into the aqueous phase considerably. Mercury pulse injection tests on the sorbent material after leaching indicate that both sorbents retain significant mercury capture capability even after the majority of bromine was removed. Testing of the Br-Ash sorbent over a wider range of pH and liquid:solid ratios resulted in leaching of <5% of mercury adsorbed on the Br-Ash. XPS analysis indicated more organically bound Br and less metal-Br bonds after leaching.

Characterization of mercury binding onto a novel brominated biomass ash sorbent by X-ray absorption spectroscopy.

Recent laboratory and field-scale experiments demonstrated the potential for brominated industrial solid waste from biomass combustion (Br-Ash) to be an efficient, cost-effective alternative to activated carbon for capturing mercury from coal-fired power plants. To develop this attractive alternative technology to a commercially sustainable level, a better understanding of mercury capture mechanisms by Br-Ash is required. For this purpose, X-ray absorption fine-structure (XAFS) spectra of Br-Ash were collected at the Hg L(III)-edge, Br K-edge and S K-edge, and analyzed to determine the local bonding environment of mercury atoms. The coordination environment of Hg was compared with that on a commercial brominated activated carbon. Our results indicate that the mercury was captured by chemisorption on both the commercial and biomass ash sorbents; however, the mercury binding environment was different for each sorbent. Mercury was found to bind to the reduced sulfur by the commercial brominated activated carbon, in contrast to mercury binding with carbon and bromine on the brominated biomass ash. Based on the results obtained, a mechanism of Hg capture involving oxidation of elemental Hg followed by binding of the oxidized mercury on the surface of the sorbent near Br was proposed for the brominated biomass ash.