Superficial peroneal neuromodulation of persistent bladder underactivity induced by prolonged pudendal afferent nerve stimulation in cats.

The purpose of this study is to determine whether superficial peroneal nerve stimulation (SPNS) can reverse persistent bladder underactivity induced by prolonged pudendal nerve stimulation (PNS). In 16 α-chloralose-anesthetized cats, PNS and SPNS were applied by nerve cuff electrodes. Skin surface electrodes were also used for SPNS. Bladder underactivity consisting of a significant increase in bladder capacity to 157.8 ± 10.9% of control and a significant reduction in bladder contraction amplitude to 56.0 ± 5.0% of control was induced by repetitive (4-16 times) application of 30-min PNS. SPNS (1 Hz, 0.2 ms) at 1.5-2 times threshold intensity (T) for inducing posterior thigh muscle contractions was applied either continuously (SPNSc) or intermittently (SPNSi) during a cystometrogram (CMG) to determine whether the stimulation can reverse the PNS-induced bladder underactivity. SPNSc or SPNSi applied by nerve cuff electrodes during the prolonged PNS inhibition significantly reduced bladder capacity to 124.4 ± 10.7% and 132.4 ± 14.2% of control, respectively, and increased contraction amplitude to 85.3 ± 6.2% and 75.8 ± 4.7%, respectively. Transcutaneous SPNSc and SPNSi also significantly reduced bladder capacity and increased contraction amplitude. Additional PNS applied during the bladder underactivity further increased bladder capacity, whereas SPNSc applied simultaneously with the PNS reversed the increase in bladder capacity. This study indicates that a noninvasive superficial peroneal neuromodulation therapy might be developed to treat bladder underactivity caused by abnormal pudendal nerve somatic afferent activation that is hypothesized to occur in patients with Fowler's syndrome.

Moxibustion for the treatment of diabetic peripheral neuropathy: A systematic review and meta-analysis following PRISMA guidelines.

BACKGROUND: At present, the effect of western-medicine (WM) therapy to treat diabetic peripheral neuropathy (DPN) is limited. Moxibustion is a representative external treatment in traditional Chinese medicine that has been beneficial to DPN. We aim to systematically assess the efficacy and safety of moxibustion in treating DPN, following PRISMA guidelines. METHODS: Eight electronic databases were searched to acquire information on eligible trials published from inception to June 1, 2019. We included randomized controlled trials (RCTs) applying moxibustion therapy with a minimum of 14-days treatment duration for DPN patients compared with placebo, no intervention, or conventional WM interventions. The primary outcomes in our study include the sensory-nerve conduction velocity (SNCV) and motor-nerve conduction velocity (MNCV). We used the Cochrane Collaboration Risk of Bias tool to assess the methodological quality of eligible RCTs. Statistical analyses were conducted using Review Manager 5.3. Risk ratios (RR) and mean differences (MD) were calculated with a 95% confidence interval (CI). The χ test was applied to assess the heterogeneity. RESULTS: In total, 11 RCTs were included that involved 927 DPN patients. Compared with the control group, there was an increase in median MNCV (MD = 6.26, 95% CI 2.64-9.89, Z = 3.39, P = .0007) and peroneal MNCV (MD = 6.45, 95% CI 5.30-7.61, P < .00001). There was also an increase in median SNCV (MD = 6.64, 95% CI 3.25-10.03, P = .0001) and peroneal SNCV (MD = 3. 57, 95% CI 2.06-5.09, Z = 4.63, P < .00001) in the treatment groups. The treatment groups receiving moxibustion therapy indicated a more significant improvement in total effectiveness rate (RR = 0.25, 95% CI 0.18-0.37, Z = 7.16, P < .00001). Toronto Clinical Scoring System indicated a significant decrease in the treatment groups (MD = -2.12, 95% CI -2.82 to 1.43, P < .00001). Only 1 study reported that treatment groups experienced no adverse reactions. The other 10 studies did not mention adverse events. CONCLUSIONS: Moxibustion therapy may be an effective and safe option for DPN patients but needs to be verified in further rigorous studies.

Superficial peroneal neuromodulation of nonobstructive urinary retention in cats.

AIMS: To determine if superficial peroneal nerve stimulation (SPNS) can improve nonobstructive urinary retention (NOUR). METHODS: In α-chloralose anesthetized cats, NOUR was induced by repetitive application (4-16 times) of 30-minute tibial nerve stimulation (TNS: 5 Hz frequency, 0.2 ms pulse width) at 4 to 6 times threshold intensity (T) for inducing toe twitches. SPNS (1 Hz, 0.2 ms) at 2 to 4 times threshold intensity (T) for inducing posterior thigh muscle contractions was applied either continuously (SPNSc) during a cystometrogram (CMG) or during voiding (SPNSv) by a surgically implanted cuff electrode or by skin surface electrodes to determine if the stimulation reduced NOUR induced by prolonged TNS. RESULTS: During control CMGs, efficient (86.4% ± 5.5%) voiding occurred with a postvoid residual (PVR) volume equal to 14.9% ± 6.2% of control bladder capacity. NOUR elicited by prolonged TNS significantly (P < .05) increased bladder capacity to 168.6% ± 15.5% of control, reduced voiding efficiency to 30.4% ± 4.8%, and increased PVR to 109% ± 9.2% of control. Using the implanted cuff electrode, SPNSc and SPNSv significantly (P < .05) increased voiding efficiency to 66.7% ± 7.4% and 65.0% ± 5.9%, respectively, and reduced PVR to 52.2% ± 11.4% and 64.3% ± 11.6%, respectively. SPNSc but not SPNSv significantly (P < .05) reduced bladder capacity to 133.4% ± 15% of control. Transcutaneous SPNSv but not SPNSc also significantly (P < .05) reversed the TNS-induced NOUR responses. CONCLUSIONS: This study shows that SPNS is effective in reversing NOUR induced by prolonged TNS. Transcutaneous SPNS provides the opportunity to develop a noninvasive neuromodulation therapy for NOUR to treat more patients than current sacral neuromodulation therapy.

Rationale and design of the theRapeutic effects of peroneal nerve functionAl electrical stimuLation for Lower extremitY in patients with convalescent poststroke hemiplegia (RALLY) study: study protocol for a randomised controlled study.

INTRODUCTION: Increasing evidence supports the utilisation of functional electrical stimulation (FES) to improve gait following stroke; however, few studies have focused exclusively on its use in the convalescent phase. In addition, its efficacy in patients with a non-Western life style has not been evaluated. METHODS AND ANALYSIS: This is a randomised, controlled, open-label multicentre study, comparing rehabilitation with and without FES. The purpose of our study is to test the hypothesis that the FES system improves walking ability in Japanese patients with hemiplegia during the convalescent phase. Two hundred patients aged 20-85 years who had an initial stroke ≤6 months prior to the enrolment, are in a convalescent phase (after the end of acute phase treatment, within 6 months after the onset of stroke) with functional ambulation classification 3 or 4 and have a hemiplegic gait disorder (drop foot) due to stroke have been recruited from 21 institutions in Japan. The patients are randomised in 1:1 fashion to usual gait rehabilitation or rehabilitation using FES (Walkaide). The trial duration is 8 weeks, and the primary outcome measured will be the change in maximum distance from baseline to the end of the trial, as measured with the 6 min walk test (6-MWT). The 6-MWT is performed barefoot, and the two treatment groups are compared using the analysis of covariance. ETHICS AND DISSEMINATION: This study is conducted in accordance with the principles of the Declaration of Helsinki and the Ethical Guidelines for Medical and Health Research Involving Human Subjects and is approved by the ethics committee of all participating institutions. The published results will be disseminated to all the participants by the study physicians. TRIAL REGISTRATION NUMBER: The University Hospital Medical Information Network-Clinical Studies Registry (UMIN000020604).

Severe hyperhomocysteinemia and peripheral neuropathy as side effects of nitrous oxide in two patients with sickle cell disease.

Nitrous oxide (N2O) is a widely used anesthetic agent. We report two patients with sickle cell disease (SCD) who presented with complications following the use of N2O. Patient 1, a 15-year-old girl, presented severe hyperhomocysteinemia, pancytopenia, vitamin B12 deficiency, and peripheral polyneuropathy after massive use of N2O for pain management. At the 1-year follow-up, hyperhomocysteinemia and B12 deficiency had resolved, but she had persisting mild symptoms of polyneuropathy. Patient 2, a 17-year-old boy, presented only severe hyperhomocysteinemia, only partially corrected by initial B12 supplementation. Careful monitoring of N2O use, especially in patients with SCD, is mandatory to prevent complications.

The long-term effects of an implantable drop foot stimulator on gait in hemiparetic patients.

Drop foot is a frequent abnormality in gait after central nervous system lesions. Different treatment strategies are available to functionally restore dorsal extension during swing phase in gait. Orthoses as well as surface and implantable devices for electrical stimulation of the peroneal nerve may be used in patients who do not regain good dorsal extension. While several studies investigated the effects of implanted systems on walking speed and gait endurance, only a few studies have focussed on the system's impact on kinematics and long-term outcomes. Therefore, our aim was to further investigate the effects of the implanted system ActiGait on gait kinematics and spatiotemporal parameters for the first time with a 1-year follow-up period. 10 patients were implanted with an ActiGait stimulator, with 8 patients completing baseline and follow-up assessments. Assessments included a 10-m walking test, video-based gait analysis and a Visual Analogue Scale (VAS) for health status. At baseline, gait analysis was performed without any assistive device as well as with surface electrical stimulation. At follow-up patients walked with the ActiGait system switched off and on. The maximum dorsal extension of the ankle at initial contact increased significantly between baseline without stimulation and follow-up with ActiGait (p = 0.018). While the spatio-temporal parameters did not seem to change much with the use of ActiGait in convenient walking speed, patients did walk faster when using surface stimulation or ActiGait compared to no stimulation at the 10-m walking test at their fastest possible walking speed. Patients rated their health better at the 1-year follow-up. In summary, a global improvement in gait kinematics compared to no stimulation was observed and the long-term safety of the device could be confirmed.

Significant Impact of Implantable Functional Electrical Stimulation on Gait Parameters: A Kinetic Analysis in Foot Drop Patients.

OBJECTIVE: Neurogenic drop foot is a common result of acquired damage of the central nervous system and can cause severe restriction of mobility. ActiGait, an implantable functional electrical stimulation device, restores ankle dorsiflexion by active peroneal nerve stimulation. The aim of our study was to evaluate its effect on foot contact pattern during normal walk. METHODS: Eight patients with drop foot who used ActiGait in everyday life performed a 20-meter comfortable walk test. Gait parameters were evaluated with an insole system (Medilogic). Percentage of biped stance in a double-step, effective foot length, width of gait, and overall plantar load were measured in comparison with and without activated drop foot stimulation. RESULTS: Effective foot length increased in all patients on average from 46.0% to 60.2% (P = 0.038). However, percentage of biped stance in a double-step showed no significant difference (31.2% vs. 27.8% on average, P = 0.063), nor did width of gait (2.6% vs. 2.4% on average, P = 0.73) and overall plantar load (3.51 N/cm2 vs. 3.39 N/cm2, P = 0.25). CONCLUSION: The ActiGait implantable drop foot stimulator significantly improves effective foot length during normal walk of patients with neurogenic drop foot. Further investigation is needed to confirm whether ActiGait has no effect on the other parameters or whether it facilitates permanent gait adaptations that persist without the activated device.

Improvement in overactive bladder symptoms in patients using functional electrical stimulation of the common peroneal nerve for walking.

OBJECTIVE: Functional electrical stimulation is used to improve walking speed and reduces falls in people with upper motor neurone foot-drop. Following anecdotal observations of changes in bladder symptoms, an observational study was performed to explore this association further. DESIGN: A total of 47 consecutive patients attending for setup with functional electrical stimulation during a six-month period were asked to complete a questionnaire assessing bladder symptoms (ICIQ-OAB (International Consultation on Incontinence Questionnaire Overactive Bladder)) at baseline and three months during routine appointments. SUBJECTS: In all, 35 (75%) had multiple sclerosis and the other 12 subjects had a total of 9 diagnoses including 3 with stroke. Other conditions included cerebral palsy, motor neurone disease, hereditary spastic paraparesis, meningioma and spinocerebellar ataxias. RESULTS: Improvement in overactive bladder symptoms was not significant in the whole cohort, however, was significant in patients with multiple sclerosis ( n = 35; mean change in ICIQ-OAB score 1.0, P = 0.043). Specifically, significant improvements were seen in urgency and urge incontinence in multiple sclerosis patients. There was a significant negative correlation of moderate strength within the multiple sclerosis cohort between baseline walking speed and subsequent change in ICIQ-OAB score (correlation coefficient of r = -0.40, P = 0.046). Thus, greater changes in bladder symptoms were seen with lower baseline walking speeds. CONCLUSION: The results of this exploratory study suggest that functional electrical stimulation use does improve overactive bladder symptoms in people with multiple sclerosis. Further exploration is needed to study this association and explore whether the mechanism is similar to that of percutaneous tibial nerve stimulation, a recognized treatment for the overactive bladder.

A clinically meaningful training effect in walking speed using functional electrical stimulation for motor-incomplete spinal cord injury.

CONTEXT/OBJECTIVE: The study aimed to investigate the presence of a training effect for rehabilitation of walking function in motor-incomplete spinal cord injury (SCI) through daily use of functional electrical stimulation (FES). SETTING: A specialist FES outpatient centre. PARTICIPANTS: Thirty-five participants (mean age 53, SD 15, range 18-80; mean years since diagnosis 9, range 5 months - 39 years) with drop foot and motor-incomplete SCI (T12 or higher, ASIA Impairment Scale C and D) able to ambulate 10 metres with the use of a walking stick or frame. INTERVENTIONS: FES of the peroneal nerve, glutei and hamstrings as clinically indicated over six months in the community. OUTCOME MEASURES: The data was analysed for a training effect (difference between unassisted ten metre walking speed at baseline and after six months) and orthotic effects (difference between walking speed with and without FES) initially on day one and after six months. The data was further analysed for a minimum clinically important difference (MCID) (>0.06 m/s). RESULTS: A clinically meaningful, significant change was observed for initial orthotic effect (0.13m/s, CI: 0.04-0.17, P = 0.013), total orthotic effect (0.11m/s, CI: 0.04-0.18, P = 0.017) and training effect (0.09m/s, CI: 0.02-0.16, P = 0.025). CONCLUSION: The results suggest that daily independent use of FES may produce clinically meaningful changes in walking speed which are significant for motor-incomplete SCI. Further research exploring the mechanism for the presence of a training effect may be beneficial in targeting therapies for future rehabilitation.

Effects of Sensitive Electrical Stimulation-Based Somatosensory Cueing in Parkinson's Disease Gait and Freezing of Gait Assessment.

This study aims to investigate the effect of a somatosensory cueing on gait disorders in subjects with Parkinson's disease (PD). After having performed stepping in place and timed up and go assessing tasks, 13 participants with PD were equipped with an electrical stimulator and an inertial measurement unit (IMU) located under the lateral malleolus on the sagittal plane. Electrodes were positioned under the arch of the foot and electrical stimulation (ES) parameters (five 500 µs/phase charge-balanced biphasic pulses delivered at 200 Hz, repeated four times at 10 Hz) adjusted to deliver a sensitive signal. Online IMU signal was processed in order to trigger ES at heel off detection. Starting from a quiet standing posture, subjects were asked to walk at their preferred speed on a path including 5 m straight line, u-turn, and walk around tasks. Three situations were considered: no stimulation baseline precondition (C0), ES condition (C1), and no stimulation baseline post-condition (C0bis), for eliminating a learning effect possibility. In ES condition (C1) the time to execute the different tasks was globally decreased in all the subjects (n = 13). Participants' results were then grouped regarding whether they experienced freezing of gait (FOG) or not during C0 no stimulation baseline precondition. In "freezer" subjects (n = 9), the time to complete the entire path was reduced by 19%. FOG episodes occurrence was decreased by 12% compared to baseline conditions. This preliminary work showed a positive global effect on gait and FOG in PD by a somatosensory cueing based on sensitive electrical stimulation.

Muscle sympathetic nerve activity response to heat stress is attenuated in chronic heart failure patients.

Heat stress evokes significant increases in muscle sympathetic nerve activity (MSNA) in healthy individuals. The MSNA response to heat stress in chronic heart failure (CHF) is unknown. We hypothesized that the MSNA response to heat stress is attenuated in CHF. Passive whole body heating was applied with water-perfused suits in 13 patients (61 ± 2 yr) with stable class II-III CHF, 12 age-matched (62 ± 2 yr) healthy subjects, and 14 young (24 ± 1 yr) healthy subjects. Mild heating (i.e., increases in skin temperature ΔTsk ~2-4°C, internal temperature ΔTcore <0.3°C) significantly decreased MSNA in CHF patients; however, it did not significantly alter the MSNA in the age-matched and young healthy subjects. Heat stress (i.e., ΔTsk ~4°C and ΔTcore ~0.6°C) raised MSNA in the age-matched (32.9 ± 3.2 to 45.6 ± 4.2 bursts/min; P < 0.001) and young (14.3 ± 1.7 to 26.3 ± 2.4 bursts/min; P < 0.001) controls, but not in CHF (46.2 ± 5.3 to 50.5 ± 5.3 bursts/min; P = 0.06). The MSNA increase by the heat stress in CHF (Δ4.2 ± 2.0 bursts/min) was significantly less than those seen in the age-matched (Δ12.8 ± 1.7 bursts/min, P < 0.05) and young (Δ12.0 ± 2.7 bursts/min, P < 0.05) control groups. These data suggest that the MSNA response to heat stress is attenuated in CHF patients. We speculate that the attenuated MSNA response to heat stress may contribute to impaired cardiovascular adjustments in CHF in a hot environment.

Hip and knee effects after implantation of a drop foot stimulator.

BACKGROUND: An active ankle dorsiflexion is essential for a proper gait pattern. If there is a failure of the foot lifting, considerable impairments occur. The therapeutic effect of an implantable peroneus nerve stimulator (iPNS) for the ankle dorsiflexion is already approved by recent studies. However, possible affection for knee and hip motion after implantation of an iPNS is not well described. OBJECTIVE: The objective of this retrospective study was to examine with a patient cohort whether the use of iPNS induces a lower-extremity flexion withdrawal response in the form of an increased knee and hip flexion during swing phase. METHODS: Eighteen subjects (12 m/6 w) treated with an iPNS (ActiGait®, Otto Bock, Duderstadt, Germany) were examined in knee and hip motion by gait analysis with motion capture system (Vicon Motion System Ltd®, Oxford, UK) and Plug-in-Gait model after a mean follow up from 12.5 months. The data were evaluated and compared in activated and deactivated iPNS. RESULTS: Only little changes could be documented, as a slight average improvement in peak knee flexion during stand phase from 1.0° to 2.5° and peak hip flexion in stance from 3.1° to 2.1° In contrast, peak knee flexion during swing appeared similar (25.3° to 25.7°) same as peak hip flexion during swing. In comparison with the healthy extremity, a more symmetric course of the knee flexion during stand phase could be shown. CONCLUSIONS: No statistical significant improvements or changes in hip and knee joint could be shown in this study. Only a more symmetric knee flexion during stand phase and a less hip flexion during stand phase might be hints for a positive affection of iPNS for knee and hip joint. It seems that the positive effect of iPNS is only based on the improvement in ankle dorsiflexion according to the recent literature.

Training and orthotic effects related to functional electrical stimulation of the peroneal nerve in stroke.

OBJECTIVE: To examine the evidence for a training effect on the lower limb of functional electrical stimulation. DESIGN: Cohort study. PATIENTS: A total of 133 patients >6 months post-stroke. METHODS: Training and orthotic effects were determined from walking speed over 10 m, associated minimal and substantial clinically important differences (i.e. >0.05 and >0.10 m/s), and Functional Ambulation Category (FAC), ranging from household walking to independent walking in the community. RESULTS: An overall significant (p < 0.01) training effect was found that was not a clinically important difference (0.02 m/s); however, "community" FAC (≥ 0.8 m/s) and "most limited community walkers" FAC (0.4-0.58 m/s), but not "household walkers" (< 0.4 m/s), benefitted from a clinically important difference. A highly significant (p< 0.001), substantial clinically important orthotic effect (0.10 m/s) was found. In terms of overall improvement of one or more FACs, 23% achieved this due to a training effect, compared with 43% due to an orthotic effect. CONCLUSION: The findings suggest that functional electrical stimulation provides a training effect in those who are less impaired. Further work, which optimizes the use of the device for restoration of function, rather than as an orthotic device, will provide greater clarity on the effectiveness of functional electrical stimulation for eliciting a training effect.

Association between clinical condition and F-waves changes in the acute phase of stroke.

OBJECTIVE: To relate F-waves with clinical and laboratory exams in the acute phase of stroke. METHODS: Inclusion criteria for this cross-sectional study were: hemiplegia, absence of previous cranial trauma, myopathy, diabetes, alcoholism or other known causes of peripheral neuropathy, and normal sensory and motor conduction. The National Institutes of Health Stroke Scale (NIHSS) score, glycemia, glucosilate hemoglobin, and CPK were obtained at admission by routine blood exams. After hospital admission, the F-wave latencies and persistence were obtained from the deep peroneal nerve using symmetrical techniques. RESULTS: Evaluation of 20 individuals - mean age 66 years, 50% male and 85% Caucasian - showed association of F-wave persistence with glycemia (r = 0.71; p < 0.001) and NIHSS categorized (NIHSS 1-7 = 65.0 x NIHSS 9-23 = 100; p = 0.004). Multivariate analysis found only association of F-wave persistence with glycemia ß = 0.59 (0.44-0.74); p < 0.001. CONCLUSION: The increase in the persistence of F-waves are associated with hyperglycemia in the acute phase of stroke.

Association between clinical condition and F-waves changes in the acute phase of stroke / Associação entre condição clínica e alterações das ondas-F na fase aguda do acidente vascular cerebral

ABSTRACT Objective To relate F-waves with clinical and laboratory exams in the acute phase of stroke. Methods Inclusion criteria for this cross-sectional study were: hemiplegia, absence of previous cranial trauma, myopathy, diabetes, alcoholism or other known causes of peripheral neuropathy, and normal sensory and motor conduction. The National Institutes of Health Stroke Scale (NIHSS) score, glycemia, glucosilate hemoglobin, and CPK were obtained at admission by routine blood exams. After hospital admission, the F-wave latencies and persistence were obtained from the deep peroneal nerve using symmetrical techniques. Results Evaluation of 20 individuals – mean age 66 years, 50% male and 85% Caucasian – showed association of F-wave persistence with glycemia (r = 0.71; p < 0.001) and NIHSS categorized (NIHSS 1-7 = 65.0 x NIHSS 9-23 = 100; p = 0.004). Multivariate analysis found only association of F-wave persistence with glycemia β = 0.59 (0.44–0.74); p < 0.001. Conclusion The increase in the persistence of F-waves are associated with hyperglycemia in the acute phase of stroke.

RESUMO Objetivo Relacionar as ondas-F com exames clínicos e laboratoriais na fase aguda do acidente vascular cerebral (AVC). Os critérios de inclusão para este estudo transversal foram: hemiplegia, ausência de trauma craniano, miopatia, diabetes, alcoolismo ou outra causa conhecida de neuropatia periférica, além de condução sensorial e motora normal. O National Institutes of Health Stroke Scale (NIHSS), glicemia, hemoglobina glicada e CPK foram obtidos na admissão por meio de exames de rotina. Após a admissão hospitalar, a latência e persistência das ondas-F foram obtidas por meio da estimulação do nervo fibular profundo utilizando técnicas simétricas. Foram avaliados 20 indivíduos – média de idade 66 anos, 50% homem e 85% caucasianos – apresentaram associação univariada da persistência das ondas-F com glicemia (r = 0.71; p < 0.001) e NIHSS categorizado (NIHSS 1–7 = 65.0 x NIHSS 9-23 = 100; p = 0.004). Na regressão multivariada foi encontrado associação somente entre persistência de ondas-F com glicemia β = 0.59(0.44–0.74); p < 0.001. Conclusão O aumento da persistência de ondas-F está associado com maior nível de glicemia na fase aguda do AVC.

The effects of anodal transcranial direct current stimulation and patterned electrical stimulation on spinal inhibitory interneurons and motor function in patients with spinal cord injury.

Supraspinal excitability and sensory input may play an important role for the modulation of spinal inhibitory interneurons and functional recovery among patients with incomplete spinal cord injury (SCI). Here, we investigated the effects of anodal transcranial direct current stimulation (tDCS) combined with patterned electrical stimulation (PES) on spinal inhibitory interneurons in patients with chronic incomplete SCI and in healthy individuals. Eleven patients with incomplete SCI and ten healthy adults participated in a single-masked, sham-controlled crossover study. PES involved stimulating the common peroneal nerve with a train of ten 100 Hz pulses every 2 s for 20 min. Anodal tDCS (1 mA) was simultaneously applied to the primary motor cortex that controls the tibialis anterior muscle. We measured reciprocal inhibition and presynaptic inhibition of a soleus H-reflex by stimulating the common peroneal nerve prior to tibial nerve stimulation, which elicits the H-reflex. The inhibition was assessed before, immediately after, 10 min after and 20 min after the stimulation. Compared with baseline, simultaneous application of anodal tDCS with PES significantly increased changes in disynaptic reciprocal inhibition and long-latency presynaptic inhibition in both healthy and SCI groups for at least 20 min after the stimulation (all, p < 0.001). In patients with incomplete SCI, anodal tDCS with PES significantly increased the number of ankle movements in 10 s at 20 min after the stimulation (p = 0.004). In conclusion, anodal tDCS combined with PES could induce spinal plasticity and improve ankle movement in patients with incomplete SCI.

Topical Citrullus colocynthis (bitter apple) extract oil in painful diabetic neuropathy: A double-blind randomized placebo-controlled clinical trial.

BACKGROUND: The aim of the present study was to examine the safety and efficacy of a topical formulation of Citrullus colocynthis in patients with painful diabetic polyneuropathy (PDPN). METHODS: The study was designed as a two-arm double-blind randomized placebo-controlled clinical trial using a parallel design. Sixty patients with PDPN were randomly allocated to receive either a topical formulation of C. colocynthis or placebo (1:1 allocation ratio) for 3 months. Patients were evaluated before and after the intervention using the neuropathic pain scale, electrodiagnostic findings, World Health Organization Biomedical Research and Education Foundation (BREF) quality of life (WHOQOL-BREF) scores, and reported adverse events. RESULTS: There was a significantly greater decrease in mean pain score after 3 months in the C. colocynthis (-3.89; 95% confidence interval [CI] -3.19, -4.60) than placebo (-2.28; 95% CI -1.66, -2.90) group (P < 0.001). Mean changes in nerve conduction velocity of the tibial nerve, distal latency of the superficial peroneal nerve and sural nerve, and sensory amplitude of the sural nerve were significantly higher in the intervention than placebo group (P < 0.001) in favour of the intervention. In the different domains of WHOQOL-BREF, there was a significant improvement only for the mean score in the physical domain. CONCLUSIONS: Application of a topical formulation of C. colocynthis fruit extract can decrease pain in patients with PDPN. It also may have some uncertain effects on nerve function and the physical domain of quality of life, which require further investigation in studies with larger sample sizes and of longer duration.

Effect of Transcutaneous Electrical Nerve Stimulation on Plantar Flexor Muscle Spasticity and Walking Speed in Stroke Patients.

BACKGROUND AND PURPOSE: Spasticity is a major disabling symptom in patients post stroke. Although studies have demonstrated that transcutaneous electrical nerve stimulation (TENS) can reduce spasticity, the duration of single session TENS is a subject of debate. The purpose of this study was to determine the sustainability of the effects of TENS applied over common peroneal nerve in the reduction of ankle plantar-flexor spasticity and improving gait speed in patients post stroke. METHODS: Thirty patients (11 women and 19 men) (mean age of 46.46 years) were randomly assigned to group 1 (task oriented exercises), group 2 (TENS for 30 min and task oriented exercises) and group 3 (TENS for 60 min and task oriented exercises) for a period of five sessions per week for 6 weeks. All patients were assessed for ankle plantar-flexor spasticity, passive ankle dorsi-flexion range of motion, clonus and timed up and go test at the time of recruitment to study, at 3 and 6 weeks of therapeutic intervention. RESULTS: The overall results of the study suggest that there was a decrease in ankle plantar flexor spasticity, ankle clonus and timed up and go score in all the groups. A greater reduction of spasticity was seen in TENS groups (groups 2 and 3) when compared to control. No significant improvement was found in timed up and go test (TUG) scores between groups. CONCLUSION: Both 30 min and 60 min of application of TENS are effective in reducing spasticity of ankle plantar flexors, improving walking ability and increase the effectiveness of task related training. Based on the effect size, we would recommend a longer duration application for the reduction of spasticity. Copyright © 2015 John Wiley & Sons, Ltd.

Effects of implantable peroneal nerve stimulation on gait quality, energy expenditure, participation and user satisfaction in patients with post-stroke drop foot using an ankle-foot orthosis.

PURPOSE: To investigate whether an implantable functional electrical stimulation (FES) system of the common peroneal nerve (ActiGait®) improves relevant aspects of gait in chronic stroke patients with a drop foot typically using an ankle-foot orthosis (AFO). METHODS: Ten community-dwelling patients participated, of whom eight patients could be analysed. Gait quality (kinematic, kinetic, and spatiotemporal characteristics) during a 10-meter comfortable walk test, normalised net energy expenditure during a 6-minute walk test, participation (physical activity and stroke impact) and user satisfaction were tested before implantation and at various moments after FES-system activation up to 26 weeks. RESULTS: Walking with FES yielded increased maximum paretic ankle plantarflexion (FES: -0.12; AFO: -4.79°, p <  0.01), higher paretic peak ankle power (FES: 1.46; AFO: 0.98 W/kg, p <  0.05) and better step length symmetry (FES: 14.90; AFO: 21.45% , p <  0.05). User satisfaction was higher for FES, but was unrelated to objective gait improvements. Energy expenditure and participation did not change. CONCLUSION: Implantable FES improved the use of residual ankle plantarflexion motion, ankle power of the paretic leg and step length symmetry compared to using an AFO, however, not resulting in decreased energy expenditure or improved participation. User satisfaction was highest with FES, but this was not related to the observed gait improvements.

Surface peroneal nerve stimulation in lower limb hemiparesis: effect on quantitative gait parameters.

OBJECTIVE: The objective of this study was to evaluate possible mechanisms for functional improvement and compare ambulation training with surface peroneal nerve stimulation vs. usual care via quantitative gait analysis. DESIGN: This study is a randomized controlled clinical trial. SETTING: The setting of this study is a teaching hospital of an academic medical center. PARTICIPANTS: One hundred ten chronic stroke survivors (>12 wks poststroke) with unilateral hemiparesis participated in this study. INTERVENTIONS: The subjects were randomized to a surface peroneal nerve stimulation device or usual care intervention. The subjects were treated for 12 wks and followed up for 6-mo posttreatment. MAIN OUTCOME MEASURES: Spatiotemporal, kinematic, and kinetic parameters of gait were the main outcome measures. RESULTS: Cadence (F3,153 = 5.81, P = 0.012), stride length (F3,179 = 20.01, P < 0.001), walking speed (F3,167 = 18.2, P < 0.001), anterior-posterior ground reaction force (F3,164 = 6.61, P = 0.004), peak hip power in preswing (F3,156 = 8.76, P < 0.001), and peak ankle power at push-off (F3,149 = 6.38, P = 0.005) all improved with respect to time. However, peak ankle ankle dorsiflexion in swing (F3,184 = 4.99, P = 0.031) worsened. In general, the greatest change for all parameters occurred during the treatment period. There were no significant treatment group × time interaction effects for any of the spatiotemporal, kinematic, or kinetic parameters. CONCLUSIONS: Gait training with peroneal nerve stimulation and usual care was associated with improvements in peak hip power in preswing and peak ankle power at push-off, which may have resulted in improved cadence, stride length, and walking speed; however, there were no differences between treatment groups. Both treatment groups also experienced a decrease in peak ankle ankle dorsiflexion in swing, although the clinical implications of this finding are unclear.