Non-invasive Transcutaneous Spinal Cord Stimulation Programming Recommendations for the Treatment of Upper Extremity Impairment in Tetraplegia.

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.

Multisite Transcutaneous Spinal Stimulation for Walking and Autonomic Recovery in Motor-Incomplete Tetraplegia: A Single-Subject Design.

OBJECTIVE: This study investigated the effect of cervical and lumbar transcutaneous spinal cord stimulation (tSCS) combined with intensive training to improve walking and autonomic function after chronic spinal cord injury (SCI). METHODS: Two 64-year-old men with chronic motor incomplete cervical SCI participated in this single-subject design study. They each underwent 2 months of intensive locomotor training and 2 months of multisite cervical and lumbosacral tSCS paired with intensive locomotor training. RESULTS: The improvement in 6-Minute Walk Test distance after 2 months of tSCS with intensive training was threefold greater than after locomotor training alone. Both participants improved balance ability measured by the Berg Balance Scale and increased their ability to engage in daily home exercises. Gait analysis demonstrated increased step length for each individual. Both participants experienced improved sensation and bowel function, and 1 participant eliminated the need for intermittent catheterization after the stimulation phase of the study. CONCLUSION: These results suggest that noninvasive spinal cord stimulation might promote recovery of locomotor and autonomic functions beyond traditional gait training in people with chronic incomplete cervical SCI. IMPACT: Multisite transcutaneous spinal stimulation may induce neuroplasticity of the spinal networks and confer functional benefits following chronic cervical SCI.

Transcutaneous Spinal Cord Stimulation Restores Hand and Arm Function After Spinal Cord Injury.

Paralysis of the upper extremity severely restricts independence and quality of life after spinal cord injury. Regaining control of hand and arm movements is the highest treatment priority for people with paralysis, 6-fold higher than restoring walking ability. Nevertheless, current approaches to improve upper extremity function typically do not restore independence. Spinal cord stimulation is an emerging neuromodulation strategy to restore motor function. Recent studies using surgically implanted electrodes demonstrate impressive improvements in voluntary control of standing and stepping. Here we show that transcutaneous electrical stimulation of the spinal cord leads to rapid and sustained recovery of hand and arm function, even after complete paralysis. Notably, the magnitude of these improvements matched or exceeded previously reported results from surgically implanted stimulation. Additionally, muscle spasticity was reduced and autonomic functions including heart rate, thermoregulation, and bladder function improved. Perhaps most striking is that all six participants maintained their gains for at least three to six months beyond stimulation, indicating functional recovery mediated by long-term neuroplasticity. Several participants resumed their hobbies that require fine motor control, such as playing the guitar and oil painting, for the first time in up to 12 years since their injuries. Our findings demonstrate that non-invasive transcutaneous electrical stimulation of the spinal networks restores movement and function of the hands and arm for people with both complete paralysis and long-term spinal cord injury.

Transcutaneous Electrical Spinal Stimulation Promotes Long-Term Recovery of Upper Extremity Function in Chronic Tetraplegia.

Upper extremity function is the highest priority of tetraplegics for improving quality of life. We aim to determine the therapeutic potential of transcutaneous electrical spinal cord stimulation for restoration of upper extremity function. We tested the hypothesis that cervical stimulation can facilitate neuroplasticity that results in long-lasting improvement in motor control. A 62-year-old male with C3, incomplete, chronic spinal cord injury (SCI) participated in the study. The intervention comprised three alternating periods: 1) transcutaneous spinal stimulation combined with physical therapy (PT); 2) identical PT only; and 3) a brief combination of stimulation and PT once again. Following four weeks of combined stimulation and physical therapy training, all of the following outcome measurements improved: the Graded Redefined Assessment of Strength, Sensation, and Prehension test score increased 52 points and upper extremity motor score improved 10 points. Pinch strength increased 2- to 7-fold in left and right hands, respectively. Sensation recovered on trunk dermatomes, and overall neurologic level of injury improved from C3 to C4. Most notably, functional gains persisted for over 3 month follow-up without further treatment. These data suggest that noninvasive electrical stimulation of spinal networks can promote neuroplasticity and long-term recovery following SCI.

Effect of insoles with arch support on gait pattern in patients with multiple sclerosis.

OBJECTIVES: This study aims to determine the effect of insoles with arch support on gait patterns in patients with multiple sclerosis (MS) and somatosensory impairment. PATIENTS AND METHODS: Ten patients (7 females, 3 males; mean age 34.9±6.8 years; range, 48 to 35 years) with clinically definite relapsing remitting MS and age- and sex-matched 10 healthy volunteers (7 females, 3 males; mean age 33.8±3.2; range, 40 to 31 years) were included in the study between January 2011 and January 2012. A medial longitudinal arch and transverse arch supporting polyurethane insole covered with foam shaped using plantar sensory feedback was used. Three-dimensional gait analysis was performed via a Vicon 612 system with six cameras. The participants initially walked barefoot and, then, wore the insoles in their short slipper socks. RESULTS: All participants were evaluated in terms of kinetics, kinematics, and temporospatial parameters with a gait analysis system. The patients with MS showed improvements in cadence and walking speed when using the insoles. Sagittal plane angles of the hip and knee were increased while using insoles (p<0.05) and ankle plantar flexion was found to be decreased, compared to barefoot walking (p<0.05). CONCLUSION: Our study results suggest that insole with arch support affects gait cycle, but does not improve gait impairments in patients with MS. Insoles may ensure plantar sensory feedback in feet during walking, which increases pressure in the mid-forefoot area.

Functional results in periacetabular osteotomy: is it possible to obtain a normal gait after the surgery?

INTRODUCTION: Gait analysis is one of the poorly understood dimensions of the functional results obtained after periacetabular osteotomy (PAO) due to dysplasia of the hip. MATERIALS AND METHODS: Spatiotemporal parameters as well as coronal and sagittal plane kinematics and moments were compared among three demographically similar groups of subjects: (i) 23 patients with excellent results according to the Harris Hip Score (HHS) (mean 6.6 years of follow-up); (ii) 12 patients with good and fair results according to the HHS (mean 9.3 years of follow-up); and (iii) 35 asymptomatic controls. RESULTS: 50% of the analysed sagittal plane kinematic parameters were significantly better (p<0.05) in the control group not only for the hip joint but also for the ipsilateral knee and ipsilateral ankle. A vast majority of the other evaluated gait parameters resulted similar among the groups (p>0.05). CONCLUSIONS: In our experience, most of the gait parameters after PAO are close to those observed in control subjects; however, the obtained pattern cannot be classified as a completely normal gait. The excellence in terms of functional results seems not to be determined by the achievement of this theoretical goal.

Knee muscle strength in multiple sclerosis: relationship with gait characteristics.

[Purpose] To investigate the relationship between isokinetic knee muscle strength and kinematic, kinetic and spatiotemporal gait parameters of patients with multiple sclerosis (MS). [Subjects and Methods] Twenty-nine MS patients (mean age 31.5±6.5) were investigated in this study. The isokinetic knee muscle strength and gait parameters of MS patients with moderate and severe disability, as determined by the expanded disability status scale (EDSS): EDSS=1-4.5 (n=22, moderate disability) and EDSS>4.5 (n=7, severe disability) were measured. [Results] Isokinetic knee muscle strength, kinematic, kinetic and spatiotemporal gait parameters differed between moderate (EDSS=1-4.5, n=22) and severe disability (EDSS>4.5, n=7). The correlation between each of gait speed, stride length, total range of knee joint movement and the four strength parameters (minimum and maximum quadriceps and hamstring muscle strengths) were significant for the MS group as a whole. Within subgroups, the correlation between minimum hamstring strength and total range of knee movement was significant only in group EDSS>4.5; minimum hamstring correlated with peak knee extensor moment in group EDSS=1-4.5, but at a reduced level of significance. [Conclusion] The present study revealed significant correlations between gait characteristics and isokinetic strength parameters of the quadriceps and hamstring muscles. Our study suggests that rehabilitation protocols for MS patients should include a critical strength training programme particularly for the hamstring and quadriceps muscles.

Yoga therapy and ambulatory multiple sclerosis Assessment of gait analysis parameters, fatigue and balance.

BACKGROUND AND OBJECTIVE: Gait impairment, falls due to balance problems and fatigue are among the most important complaints in patients with multiple sclerosis (MS) and cause significant functional limitation. Use of complementary and alternative medicine (CAM) to help symptom management and to improve quality of life is growing among MS patients. Yoga is widely used as one of these CAM interventions, however, the number of studies that show the efficacy of yoga training in MS is inadequate. In this study, we aimed to evaluate the effects of a short term yoga program on fatigue, balance and gait in patients with MS. METHOD: Eight volunteer ambulatory MS patients with clinically definite relapsing remitting MS whose Expanded Disability Status Score (EDSS) is less than or equal to 6.0, and eight healthy subjects were included in the study. Patients participated in 12 weeks of a bi-weekly yoga program under supervision. At their baseline and after yoga therapy, the Fatigue Severity Scale (FSS) and Berg Balance Scale (BBS) are used to assess fatigue and balance. Three dimensional gait analysis is done using the Vicon 612 system with six cameras and two Bertec force plates, before and after therapy. RESULTS: After short term yoga therapy, statistically significant achievements were obtained in fatigue, balance, step length and walking speed. Although sagittal plane pelvis and hip angles, ankle plantar flexor moment, powers generated at the hip and ankle joints at the pre-swing were improved, the improvements were not statistically significant. CONCLUSION: Yoga therapy is a safe and beneficial intervention for improving fatigue, balance and spatiotemporal gait parameters in patients with MS. Further studies with a larger sample size and longer follow-up will be needed to evaluate the long term effects of yoga therapy.

Pulmonary abnormalities on high-resolution computed tomography in ankylosing spondylitis: relationship to disease duration and pulmonary function testing.

The aim of this study was to identify the pulmonary abnormalities on high-resolution computed tomography (HRCT) in patients with ankylosing spondylitis (AS) and to examine the relationship with the duration of disease and pulmonary function test (PFT) results. Twenty male AS patients with a mean age of 37.1 ± 9.4 years were enrolled in this study. The patients were assigned into 2 groups according to disease duration: patients with disease duration <10 years (n = 10) and ≥ 10 years (n = 10). All patients underwent clinical examination, PFT and HRCT. HRCT revealed abnormalities in 14 patients (70%). The most common findings were apical fibrosis (45%) and emphysema (25%). HRCT findings were more prominent in late AS patients (disease duration ≥ 10 years) (P = 0.015). PFT were considered as abnormal in 4 patients (20%). While 3 patients had a restrictive type pulmonary deficiency, one patient had a mild obstructive pattern. Three of these patients had concomitant HRCT abnormalities. On the other hand, 10 patients with normal PFT had abnormalities on HRCT. These findings suggest that pulmonary involvement in AS patients without respiratory symptoms could be sensitively detected by HRCT. However, the clinical significance of these radiological abnormalities should be examined in further prospective studies.

Evaluation of cardiac autonomic functions in patients with ankylosing spondylitis via heart rate recovery and heart rate variability.

OBJECTIVE: The aim of this study was to evaluate heart rate variability (HRV) and heart rate recovery (HRR) in otherwise healthy ankylosing spondylitis (AS) patients and control subjects. METHODS: A total of 28 patients with AS and 30 volunteers matched for age and sex were enrolled. All subjects underwent HRV analysis, exercise testing (ET), and transthoracic echocardiography. HRR indices were calculated by subtracting first, second, and third minute heart rates (HR) from the maximal HR. RESULTS: The AS and control groups were similar with respect to age (28.7 ± 5.7 vs. 29.3 ± 5.8 years), gender distribution [(male/female) 24/4 vs. 26/4], and left ventricular ejection fraction (LVEF) (63.8 ± 2.8% vs. 65.7 ± 3.6%). Mean HRR1 (24.8 ± 4.2 vs. 28.8 ± 5.5, P = 0.001) and HRR2 (42.0 ± 4.4 vs. 48.0 ± 6.3, P = 0.001) values were significantly higher in control group. SDNN, SDANN, RMSDD, and PNN50 significantly decreased; LF and LF/HF increased in AS patients compared with control subjects. CONCLUSIONS: Patients with AS has lower HRR and HRV indices with respect to normal subjects. Cardiac autonomic functions might be involved in AS patients even in patients without cardiac symptoms.

Forearm bone mineral density measurements in thoracic outlet syndrome.

Denervation of sensory and sympathetic nerve fibers and reduced blood flow result in decreased bone mineral density (BMD). In this study, we aim to detect the effect of compression of brachial plexus and subclavian vessels on the forearm BMD in patients with thoraric outlet syndrome (TOS). Twenty-three patients with TOS (17 females and 6 males) were enrolled in the study. Thirty-three extremities of the patients with TOS were classified as true neurogenic (1), vascular (15) and disputed neurogenic TOS (17). Thirty upper extremities of 15 age- and sex-matched healthy subjects were evaluated as controls. Electrophysiological testings and Doppler ultrasonography were performed. Comparisons of the dominant and the non-dominant forearm BMD between patients and controls, and between the involved and the non-involved sides in TOS patients revealed no significant differences (P < 0.05). In conclusion, intermittent compression of brachial plexus and subclavian vessels in patients with disputed and vascular TOS does not seem to affect forearm BMD. Further studies are needed to detect the effect of persistent neurovascular compression in TOS.

Ultrasonographical evaluation of the Achilles' tendon in psoriasis patients.

BACKGROUND: Psoriasis is a common dermatological disease with erythematous plaques where articular and extra articular findings (tenosynovitis and enthesitis) may well accompany. The aim of this current study was to evaluate the Achilles' tendon of psoriasis patients with ultrasonography. METHODS: The study comprised 30 psoriasis patients and 20 healthy controls. Ankle ultrasonography was performed with posterior approach, the joint in neutral or in a little dorsiflexed position. The statistical analysis was carried out with a Student's t-test and Spearman correlation tests. RESULTS: The mean values of Achilles' tendon thickness of two groups were compared: the psoriatic group was found to have thicker tendon measurements (P = 0.00). The tendons of the patients with radiologically proven enthesopathy were found to be even thicker (P = 0.001). CONCLUSIONS: We encourage the use of diagnostic ultrasonography for evaluation of enthesopathy manifestations in psoriasis patients as an adjunct to conventional methods owing to its convenience and promising results.

Cystic hygroma in the quadriceps muscle: a sanguine diagnosis for knee pain.

Reported here is a 28-year-old female who presented with severe right knee pain and swelling nearby the joint. Ultrasonography, magnetic resonance imaging and eventually surgery were performed. She was diagnosed to have a cystic hygroma in the vastus lateralis muscle. This is the first patient of a cystic hygroma in the quadriceps muscle.

History of fibromyalgia: past to present.

Fibromyalgia syndrome (FMS) is now a recognized clinical entity causing chronic and disabling pain. For several centuries, muscle pains have been known as rheumatism and then as muscular rheumatism. The term fibrositis was coined by Gowers in 1904 and was not changed to fibromyalgia until 1976. Smythe laid the foundation of modern FMS in 1972 by describing widespread pain and tender points. The first sleep electroencephalogram study was performed in 1975. The first controlled clinical study with validation of known symptoms and tender points was published in 1981. This same study also proposed the first data-based criteria. The important concept that FMS and other similar conditions are interconnected was proposed in 1984. The first American College of Rheumatology criteria were published in 1990 and neurohormonal mechanisms with central sensitization were developed in the 1990s. Serotonergic/norepinephric drugs were first shown to be effective in 1986.

Corticosteroid injection vs. nonsteroidal antiinflammatory drug and splinting in carpal tunnel syndrome.

OBJECTIVE: To compare the efficacy of local corticosteroid injection to a nonsteroidal antiinflammatory drug and splinting for the treatment of carpal tunnel syndrome. DESIGN: This study was a prospective, unblinded, randomized clinical trial with an 8-wk follow-up. Thirty-three hands of 23 patients were randomly treated with acemetacine and splinting (group A) or with corticosteroid injection (group B). Clinical (symptom severity scale, visual analog scale, Tinel and Phalen tests) and electromyographic evaluations were performed on initial visit and after 8 wk. RESULTS: Clinical and electromyographic parameters, which were similar at baseline, were improved in both groups after treatment. Improvement was also similar when both groups were compared at 8 wk. CONCLUSION: Both splinting combined with the use of a nonsteroidal antiinflammatory drug and steroid injection into the carpal tunnel resulted in significant improvement in carpal tunnel syndrome.