Efficacy of a fixed combination of palmitoylethanolamide and acetyl-l-carnitine (PEA+ALC FC) in the treatment of neuropathies secondary to rheumatic diseases.

BACKGROUND: The neurologic complications of rheumatic diseases (RDs) are highly variable, and their manifestations are linked to the pathogenesis and clinical phenotype of the specific RDs. In rheumatoid arthritis, for example, the peripheral nervous system is most commonly involved and mononeuritis multiplex, nerve entrapment and vasculitic sensorimotor neuropathies are not uncommon. Often the therapy for these disorders is not easy and is characterized by the use of different drugs. Palmitoylethanolamide (PEA) has been tested in a wide variety of animal models and has been evaluated in several clinical studies for nerve compression syndromes, demonstrating that PEA acts as an effective and safe analgesic compound. Acetyl-L-Carnitine (ALC) has also been shown to be an effective and safe treatment in painful peripheral neuropathy. In the last years the synergistic effect between PEA and ALC has been demonstrated. The aim of our study was to evaluate the efficacy of supplementation of standard therapy (STh) with Kalanit® (Chiesi Italia Spa; Parma, Italy) in patients with peripheral neuropathy secondary to RDs. METHODS: Patients at the time of enrollment were affected by RDs with neuropathy from <12 months, documented by electromyography. The analyzed patients were treated with the STh chosen according to their rheumatic disease (RA or SpA) and for their neuropathy (e.g. analgesic, NSAIDs, pregabalin or gabapentin) as per clinical practice. The sample was divided into 2 groups: group 1, patients treated with STh, to which a fixed combination of PEA (600 mg) + ALC (500 mg) (Kalanit®) was added twice a day for 2 weeks and then once a day for 6 months; group 2, patients treated only with STh. Each patient underwent clinical evaluations and questionnaires were administered in order to evaluate their neuropathy and the efficacy of the therapy. RESULTS: In group 1, 18 patients suffering from sciatic pain, 16 patients from carpal tunnel syndrome and 8 patients with peripheral neuropathy of the lower limbs were included and PEA + ALC FC was added to STh. These patients were compared with patients from group 2, who had the same pathology and demographic characteristics: 20 patients with sciatic pain, 15 with carpal tunnel syndrome and 5 with peripheral neuropathy of the lower limbs, respectively; this group was treated with STh only. Patients treated with PEA + ALC FC had a significant improvement in pain VAS compared to patients treated with group 2 in all the diseases analyzed (P value: sciatic pain 0.032, carpal tunnel syndrome 0.025 and lower limbs neuropathy 0.041). Patients in group 1 showed a significant improvement compared to patients treated in group 2 also from a specific score. Specifically, LBP-IQ showed significant improvement in group one (P value: 0.031), as did CHFD (P=0.011) and NPQ (P=0.025). CONCLUSIONS: The synergistic effect of PEA and ALC seems to have a further advantage in the treatment of this type of pathology, including the anti-inflammatory effect but also in terms of therapy optimization and therefore of better adherence to treatments. Our study shows that it is important to identify the type of pain to follow an accurate diagnostic algorithm, considering the clinical characteristics of the patient and carefully evaluate the indication, preferring a multimodal approach.

Microcirculatory Flux and Pulsatility in Arterial Leg Ulcers is Increased by Intermittent Neuromuscular Electrostimulation of the Common Peroneal Nerve.

BACKGROUND: Neuromuscular electrical stimulator (NMES) devices increase blood flow to the lower limb by a process of intermittent muscular contraction initiated by a transdermal stimulus to the common peroneal nerve. However, its effects on localized microvascular blood supply to lower limb wounds are unknown. This study is a single-center open label study measuring the effect of neuromuscular stimulation of the common peroneal nerve on the microvascular blood flow within the wound bed of arterial leg ulcers. METHODS: Eights patients with ischemic lower limb wounds had an NMES (geko™) applied to the common peroneal nerve. Baseline and intervention analysis of blood flow to the wound bed and edge was performed using Laser Speckle Contrast Imaging. Mean flow (flux) and pulse amplitude (pulsatility) were measured. RESULTS: Stimulation of the common peroneal nerve with the NMES resulted in a significantly increased flux and pulsatility in both the wound bed and the wound edge in all 8 patients. CONCLUSIONS: Neuromuscular electrical stimulation immediately increases microcirculatory blood flow to the wound bed and edge in patients with ischemic lower limb wounds. These data may provide mechanistic insight into the clinical efficacy of NMES in healing wounds. www.clinicaltrials.gov NCT03186560.

A Case Report of Thoracic Endovascular Aneurysm Repair under Local Anesthesia with Resolution of Acute Onset Lower Extremity Paraplegia from an Acute Complicated Type B Aortic Dissection.

Spinal cord ischemia (SCI) is a rare presenting symptom of acute complicated type B aortic dissection, occurring in approximately 3% of patients . We present a case report of a patient with this presentation who had observed resolution of his paraplegia symptoms immediately after placement of a thoracic stent graft under local anesthesia. The temporal association between true lumen flow restoration and paraplegia resolution intraoperatively is a novel finding. We feel that this case report may provide support for recognized cord perfusion theory , as well as contribute to the understanding of the time frame associated with SCI and reversibility of paraplegia.

A systematic review of lower extremity electrical stimulation for treatment of walking impairment in peripheral artery disease.

Lower extremity peripheral artery disease (PAD) induces an ischemic pain in the lower limbs and leads to walking impairment. Electrical stimulation has been used in patients with PAD, but no systematic review has been proposed to address the efficacy of the technique as a treatment for walking impairment in PAD. A systematic search was performed to identify trials focused on electrical stimulation for the treatment of walking impairment in patients with PAD in the Cochrane Central Register, PubMed, Embase, and the Web of Science. Studies were included where the primary outcomes were pain-free walking distance and/or maximal walking distance. When appropriate, eligible studies were independently assessed for quality using the Cochrane Collaboration's tool for assessing risk of bias. Five studies eligible for inclusion were identified, of which only two were randomized controlled studies. Trial heterogeneity prevented the use of the GRADE system and the implementation of a meta-analysis. Three types of electrical stimulation have been used: neuromuscular electrical stimulation (NMES, n = 3), transcutaneous electrical stimulation (n = 1), and functional electrical stimulation (n = 1). The two available randomized controlled studies reported a significant improvement in maximal walking distance (+40 m/+34% and +39 m/+35%, respectively) following a program of NMES. Owing to the low number of eligible studies, small sample size, and the risk of bias, no clear clinical indication can be drawn regarding the efficacy of electrical stimulation for the management of impaired walking function in patients with PAD. Future high-quality studies are required to define objectively the effect of electrical stimulation on walking capacity.

The Effectiveness of Topical Cannabidiol Oil in Symptomatic Relief of Peripheral Neuropathy of the Lower Extremities.

BACKGROUND: Peripheral neuropathy can significantly impact the quality of life for those who are affected, as therapies from the current treatment algorithm often fail to deliver adequate symptom relief. There has, however, been an increasing body of evidence for the use of cannabinoids in the treatment of chronic, noncancer pain. The efficacy of a topically delivered cannabidiol (CBD) oil in the management of neuropathic pain was examined in this four-week, randomized and placebocontrolled trial. METHODS: In total, 29 patients with symptomatic peripheral neuropathy were recruited and enrolled. 15 patients were randomized to the CBD group with the treatment product containing 250 mg CBD/3 fl. oz, and 14 patients were randomized to the placebo group. After four weeks, the placebo group was allowed to crossover into the treatment group. The Neuropathic Pain Scale (NPS) was administered biweekly to assess the mean change from baseline to the end of the treatment period. RESULTS: The study population included 62.1% males and 37.9% females with a mean age of 68 years. There was a statistically significant reduction in intense pain, sharp pain, cold and itchy sensations in the CBD group when compared to the placebo group. No adverse events were reported in this study. CONCLUSION: Our findings demonstrate that the transdermal application of CBD oil can achieve significant improvement in pain and other disturbing sensations in patients with peripheral neuropathy. The treatment product was well tolerated and may provide a more effective alternative compared to other current therapies in the treatment of peripheral neuropathy.

Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization.

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

Electrical Stimulation in Lower Limb During Exercise to Improve Gait Speed and Functional Motor Ability 6 Months Poststroke. A Review with Meta-Analysis.

INTRODUCTION: Stroke is the third most common cause of disability in adults over 65 years of age and there are 30.7 million survivors after stroke worldwide. Stroke survivors have the highest odds of reporting severe disability and the greatest variety of individual domains of disability compared to a range of other conditions. Electrical stimulation of peripheral sensory-motor systems increases voluntary movement and muscle strength and thereby raises the activities of daily living (ADL). Little is known about electrical stimulation during physical activity in rehabilitation; the objective of this review is therefore to investigate whether external electrical stimulation combined with activity improves functional motor ability and gait speed in patients who have experienced a stroke within the last 6 months. METHODS: A review and random effects meta-analysis of randomized controlled clinical trials on gait speed and functional motor ability measured with Barthel Index (BI) and Bergs Balance Scale (BBS). RESULTS: Eight trials were included (n = 191). Explorative meta-analysis was performed on gait speed (5 trials, n = 120), BI (3 trials, n = 74), and BBS (3 trial n = 79). A small, significant difference on gait speed 0.15 (95% confidence interval [CI]: 0.08-0.21) m/s, but no difference in BI 2.88 (95 % CI: -3.3 to 9.07) and BBS 1.73 (95% CI: -2.8 to 6.27). CONCLUSIONS: Sparse, low-quality evidence indicates that electrical stimulation combined with activity is a relevant intervention to improve ADL within 6 months poststroke.

Pathological Observation of Blood Stasis Syndrome in Non-diabetic Peripheral Neuropathies: A Retrospective Analysis Based on Nerve Biopsy.

OBJECTIVE: To investigate the pathological features of blood stasis syndrome (BSS) in non-diabetic peripheral neuropathy. METHODS: Clinical data of 31 patients with non-diabetic peripheral neuropathy who had undergone nerve biopsy during December 2004 and December 2010 in Xuanwu Hospital Capital Medical University were retrospectively analyzed. According to Chinese medicine (CM) syndrome differentiation and signs, 26 patients were blood stasis type and 5 patients were non-blood stasis type. Clinical and pathological data were compared in detail. RESULTS: Clinically, although both groups shared similar symptoms of limb numbness, weakness and sensory disturbances, the prevalence of neuralgia was much grievous in BSS group (73.1%, 26/31) compared with the non-BSS group (0%, 0/5). As for signs, dermal nutrients disturbance (84.6%, 22/26), dark or purple tongue (100.0%, 26/26), and sublingual varices (80.7%, 21/26) were more common in the BSS group than the non-BSS group (0%, 60%, 20%, respectively). The prevalence of qi deficiency cases (19/26) in the BSS group was significantly higher compared with the non-BSS group (1/5). The unique histological manifestations of BSS were axonal degeneration (16/26 vs 2/5 in non-BSS group), which was the hallmark of ischemia. Cases with BSS had prominent microangiopathy (61.5%, 16/26), manifested as epineurium vasculitis (inflammatory cell infiltrated to the vessel wall, obliteration and recanalization, vascular proliferation, extravascular hemosiderin deposition), angiotelectasis, proliferation and hyaline degeneration of endoneurium capillary. In the BSS group, impaired blood-nerve barrier was indicated by sub-perineurial edema (46.2%, 11/26) and endoneurial edema (15.4%, 4/26). The Renaut body (15.4%, 4/26) and amyloid deposition (3.8%, 1/26) found in the BSS group were absent in the non-BSS group. CONCLUSIONS: BBS was common in non-diabetic peripheral neuropathies. The nerves exhibited ischemic alteration of primary axon degeneration and secondary demyelination. The interstitial tissue revealed microcirculation impairment, blood-nerve barrier disturbance, amyloid deposition and proliferation changes. The high prevalence of qi deficiency also highlights the therapy of promotion of blood circulation and removal of blood stasis.

Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): results from a randomised controlled feasibility trial.

OBJECTIVES: To determine the feasibility of undertaking a randomised controlled effectiveness trial evaluating the use of a perineural catheter (PNC) after major lower limb amputation with postoperative pain as the primary outcome. DESIGN: Randomised controlled feasibility trial. SETTING: Two vascular Centres in South Wales, UK. PARTICIPANTS: 50 patients scheduled for major lower limb amputation (below or above knee) for complications of peripheral vascular disease. INTERVENTIONS: The treatment arm received a PNC placed adjacent to the sciatic or tibial nerve at the time of surgery, with continuous infusion of levobupivacaine hydrochloride 0.125% for up to 5 days. The control arm received neither local anaesthetic nor PNC. Both arms received usual perioperative anaesthesia and postoperative analgesia. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcomes were the proportion of eligible patients who were randomised and the proportion of recruited patients who provided primary effectiveness outcome data. Secondary outcomes were: the proportion of recruited patients reaching 2 and 6 month follow-up and supplying pain data; identification of key cost drivers; development of an economic analysis framework for a future effectiveness trial; identification of barriers to recruitment and site set-up; and identification of the best way to measure postoperative pain. RESULTS: Seventy-six of 103 screened patients were deemed eligible over a 10 month period. Fifty (64.5%) of these patients were randomised, with one excluded in the perioperative period. Forty-five (91.3%) of 49 recruited patients provided enough pain scores on a 4-point verbal rating scale to allow primary effectiveness outcome evaluation. Attrition rates were high; 18 patients supplied data at 6 month follow-up. Costs were dominated by length of hospital stay. Patients and healthcare professionals reported that trial processes were acceptable. CONCLUSIONS: Recruitment of patients into a trial comparing PNC use to usual care after major lower limb amputation with postoperative pain measured on a 4-point verbal rating scale is feasible. Evaluation of longer-term symptoms is difficult. TRIAL REGISTRATION NUMBER: ISRCTN: 85 710 690. EudraCT: 2016-003544-37.

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).

Acupuncture for the treatment of lower limb diabetic peripheral neuropathy: a systematic review.

OBJECTIVE: To examine evidence for acupuncture interventions in the management of diabetes-related peripheral neuropathy (DPN) symptoms. METHODS: Five electronic databases were searched up to June 2017 for studies that included participants with symptoms of DPN, used an acupuncture intervention, and reported before-and-after DPN-related outcome measures. Two reviewers independently performed the data extraction. The level of homogeneity was assessed, and studies were appraised using the Cochrane Risk of Bias tool, the STRICTA guidelines for acupuncture reporting and the NICMAN scale for acupuncture quality. RESULTS: Ten studies with 432 participants were included: three randomised controlled trials (RCTs), two pilot RCTs, three uncontrolled clinical trials, one quasi-RCT and one prospective case series. Improvements in DPN pain symptoms were reported by all studies. Heterogeneity of outcome measures prevented a meta-analysis. Variations were found in needle retention time and point selection, as well as total number and frequency of treatments. Common acupuncture point selections were ST36 and SP6. Half of the studies used local point selection. Studies conducted outside China had better acupuncture reporting and quality according to the STRICTA checklist and NICMAN scales, respectively. Risk of bias was high or unclear in the majority of studies for all domains except attrition bias. CONCLUSIONS: Acupuncture for DPN appears to improve symptoms. However, the application of acupuncture varies greatly, and the quality of included studies was generally low. Available studies have varying methodologies and different outcome measures. Further, suitably powered studies using appropriate DPN outcome measures are required.

Potential Nervous System Sensitization in Patients With Persistent Lower Extremity Tendinopathies: 3 Case Reports.

BACKGROUND: Tendinopathy is a condition often associated with pain and functional and sport performance limitations. While targeted exercise prescriptions are often effective, many patients with tendinopathy develop persistent symptoms. Emerging evidence suggests a possible link between nervous system sensitization and tendinopathy. If so, identifying and treating specific pain mechanisms may improve outcomes. CASE DESCRIPTION: Three patients were seen in physical therapy for complaints of ongoing chronic tendon pain and self-reported disability, despite being treated previously and receiving evidence-informed care. Upon examination, each patient demonstrated signs consistent with possible dysfunction of central pain mechanisms. Joint mobilization, pain neuroscience education, and aerobic exercise were primary interventions in each case to decrease pain and improve function. OUTCOMES: The 3 patients were treated for 5 sessions over the course of 8 weeks. Clinically significant improvement was noted in measures of pain, self-reported function, and pressure pain thresholds. At discharge, all patients were able to run without symptoms, and improvement was maintained at 1-year follow-up. DISCUSSION: Tendinopathy, while often described as local pain and dysfunction, may be associated with dysfunction of the nervous system. Identifying and treating pain mechanisms in addition to relevant impairments may be an appropriate intervention approach for individuals with tendinopathy. LEVEL OF EVIDENCE: Therapy, level 4. J Orthop Sports Phys Ther 2019;49(4):272-279. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8600.

Paradigms of Lower Extremity Electrical Stimulation Training After Spinal Cord Injury.

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with numerous cardiometabolic health consequences. These changes are likely to increase the risk of developing chronic secondary conditions and impact the quality of life in persons with SCI. Surface neuromuscular electrical stimulation evoked resistance training (NMES-RT) was developed as a strategy to attenuate the process of skeletal muscle atrophy, decrease ectopic adiposity, improve insulin sensitivity and enhance mitochondrial capacity. However, NMES-RT is limited to only a single muscle group. Involving multiple muscle groups of the lower extremities may maximize the health benefits of training. Functional electrical stimulation-lower extremity cycling (FES-LEC) allows for the activation of 6 muscle groups, which is likely to evoke greater metabolic and cardiovascular adaptation. Appropriate knowledge of the stimulation parameters is key to maximizing the outcomes of electrical stimulation training in persons with SCI. Adopting strategies for long-term use of NMES-RT and FES-LEC during rehabilitation may maintain the integrity of the musculoskeletal system, a pre-requisite for clinical trials aiming to restore walking after injury. The current manuscript presents a combined protocol using NMES-RT prior to FES-LEC. We hypothesize that muscles conditioned for 12 weeks prior to cycling will be capable of generating greater power, cycle against higher resistance and result in greater adaptation in persons with SCI.

Relationship of Spinal Cord Injury Level and Duration to Peak Aerobic Capacity With Arms-Only and Hybrid Functional Electrical Stimulation Rowing.

OBJECTIVE: The aim of the study was to assess the relationship of spinal cord injury level and duration to peak aerobic capacities during arms-only rowing compared with hybrid Functional Electrical Stimulation (FES)-rowing. DESIGN: Comparison of peak aerobic capacity (VO2), peak ventilation, peak respiratory exchange ratio, and peak heart rate were measured during arms-only rowing and FES-rowing obtained from graded exercise tests. RESULTS: Peak aerobic values were strongly related to injury level and injury duration for both arms-only rowing (r = 0.67, P < 0.05) and FES-rowing (r = 0.61, P < 0.05). Peak aerobic capacities were greater across all injury levels and durations with FES-rowing compared with arms-only rowing. Differences in VO2 were inversely related to injury level (r = 0.55, P < 0.05) with greater increases in VO2 in higher level injuries. Injury durations of less than 2 yrs had greater percent increases in VO2 with FES-rowing. CONCLUSIONS: FES-rowing acutely post injury may have the greatest effect to maintain function and improve VO2. This impact seems to be greatest in those with higher level injuries.

Bilateral Transcutaneous Electrical Nerve Stimulation Improves Lower-Limb Motor Function in Subjects With Chronic Stroke: A Randomized Controlled Trial.

BACKGROUND: Transcutaneous electrical nerve stimulation (TENS) has been used to augment the efficacy of task-oriented training (TOT) after stroke. Bilateral intervention approaches have also been shown to be effective in augmenting motor function after stroke. The purpose of this study was to compare the efficacy of bilateral TENS combined with TOT versus unilateral TENS combined with TOT in improving lower-limb motor function in subjects with chronic stroke. METHODS AND RESULTS: Eighty subjects were randomly assigned to bilateral TENS+TOT or to unilateral TENS+TOT and underwent 20 sessions of training over a 10-week period. The outcome measures included the maximal strength of the lower-limb muscles and the results of the Lower Extremity Motor Coordination Test, Berg Balance Scale, Step Test, and Timed Up and Go test. Each participant was assessed at baseline, after 10 and 20 sessions of training and 3 months after the cessation of training. The subjects in the bilateral TENS+TOT group showed greater improvement in paretic ankle dorsiflexion strength (ß=1.32; P=0.032) and in the completion time for the Timed Up and Go test (ß=-1.54; P=0.004) than those in the unilateral TENS+TOT group. However, there were no significant between-group differences for other outcome measures. CONCLUSIONS: The application of bilateral TENS over the common peroneal nerve combined with TOT was superior to the application of unilateral TENS combined with TOT in improving paretic ankle dorsiflexion strength after 10 sessions of training and in improving the completion time for the Timed Up and Go test after 20 sessions of training. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02152813.

Unisensory and multisensory Self-referential stimulation of the lower limb: An exploratory fMRI study on healthy subjects.

BACKGROUND: The holistic view of the person is the essence of the physiotherapy. Knowledge of approaches that develop the whole person promotes better patient outcomes. Multisensory Self-referential stimulation, more than a unisensory one, seems to produce a holistic experience of the Self ("Core-Self"). OBJECTIVES: (1) To analyze the somatotopic brain activation during unisensory and multisensorial Self-referential stimulus; and (2) to understand if the areas activated by multisensorial Self-referential stimulation are the ones responsible for the "Core-Self." METHODS: An exploratory functional magnetic resonance imaging (fMRI) study was performed with 10 healthy subjects, under the stimulation of the lower limbs with three Self-referential stimuli: unisensory auditory-verbal, unisensory tactile-manual, and multisensory, applying the unisensory stimuli simultaneously. RESULTS: Unisensory stimulation elicits bilateral activations of the temporoparietal junction (TPJ), of the primary somatosensory cortex (S1), of the primary motor cortex (BA4), of the premotor cortex (BA6) and of BA44; multisensory stimulation also elicits activity in TPJ, BA4, and BA6, and when compared with unisensory stimuli, activations were found in: (1) Cortical and subcortical midline structures-BA7 (precuneus), BA9 (medial prefrontal cortex), BA30 (posterior cingulated), superior colliculum and posterior cerebellum; and (2) Posterior lateral cortex-TPJ, posterior BA13 (insula), BA19, and BA37. Bilateral TPJ is the one that showed the biggest activation volume. CONCLUSION: This specific multisensory stimulation produces a brain activation map in regions that are responsible for multisensory Self-processing and may represent the Core-Self. We recommend the use of this specific multisensory stimulation as a physiotherapy intervention strategy that might promote the Self-reorganization.

Step Ergometer Training Augmented With Functional Electrical Stimulation in Individuals With Chronic Spinal Cord Injury: A Feasibility Study.

Spinal cord injury (SCI) often results in loss of upright mobility and independence subsequently challenging rehabilitation practitioners for meaningful intervention strategies. The objective of this study was to evaluate the feasibility and potential impact on walking function of the stimulation and ergometer training protocol (STEP) in chronic SCI. Fourteen individuals with a chronic motor incomplete SCI (>1-year post injury) were enrolled in the study. The intervention consisted of a 12-week walking training program delivered three times per week from 20 up to 45 min in combination with 10 channels of FES on a step ergometer. Subsequent to this training, 30 min over ground walking training was performed. Ten out of the 14 participants completed the trial (71%). All participants who completed the intervention increased their walking speed by an average of 0.13 m/s (0.08) and walking endurance by an average of 117 ft (84 ft). For those who completed the trial, 50% demonstrated increases on the Walking Index for Spinal Cord Injury II by at least one level while 60% demonstrated an increase in lower extremity motor scores; all completing the Timed Up and Go Test at baseline demonstrated a reduction in time to complete during post-test evaluation. Recruitment objectives were attained. Overall retention was lower than anticipated with 29% withdrawing secondary to issues with lower extremity pain and exertional demands; however, no other adverse events occurred. Improvements in mobility outcomes generated by the STEP show promise in the context of feasibility and warrant further investigation to evaluate efficacy in comparison to other walking recovery interventions. The STEP was well-tolerated by participants who were >1 year and less than 10 years post SCI. Those completing the protocol exhibited improvements in commonly used SCI walking outcome measures.

Development of Functional Electrical Stimulation Rowing: The Rowstim Series.

Potentially, functional electrical stimulation (FES)-assisted exercise may have an important therapeutic role in reducing comorbidities associated with spinal cord injury (SCI). Here, we present an overview of these secondary life-threatening conditions, discuss the rationale behind the development of a hybrid exercise called FES rowing, and describe our experience in developing FES rowing technology. FES rowing and sculling are unique forms of adaptive rowing for those with SCI. The paralyzed leg musculature is activated by multiple channels of electrical pulses delivered via self-adhesive electrodes attached to the skin. The stimulated muscle contractions are synchronized with voluntary rowing movements of the upper limbs. A range of steady-state FES rowing exercise intensities have been demonstrated from 15.2 ± 1.8 mL/kg/min in tetraplegia to 22.9 ±7.1 mL/kg/min in paraplegia. We expect that such high levels may help some to achieve significant reductions in the risks to their health, particularly where a dose-response relationship exists as is the case for cardiovascular disease and Type II diabetes. Furthermore, preliminary results suggest that cyclical forces more than 1.5 times body weight are imposed on the leg long bones which may help to reduce the risk of fragility fractures. We have demonstrated the feasibility of FES rowing on land and water using adapted rowing technology that includes; a fixed stretcher indoor ergometer (adapted Concept 2, Model E), a floating stretcher indoor ergometer (adapted Concept 2 Dynamic), a turbine powered water rowing tank, a custom hydraulic sculling simulator and a single scull (adapted Alden 16). This has involved volunteers with paraplegia and tetraplegia with SCI ranging from C4 to T12 AIS A using at least 4-channels of surface electrical stimulation. FES rowers, with SCI, have competed alongside non-SCI rowers over the Olympic distance of 2000 m at the British Indoor Rowing Championships in 2004, 2005, and 2006 and the World Indoor Rowing Championships in 2006 (CRASH-B's) in Boston, MA, USA. The best 2000 m FES rowing performance to date has been achieved by a 23-year-old male, Tom Aggar T12 AIS A, in 10 min 28 s. Moreover, two of our FES rowers with complete paraplegia have gone on to successfully compete in the Adaptive Rowing arms-only category (AM1x) at the World Rowing Championships and Paralympic Games.

Artificial Walking Technologies to Improve Gait in Cerebral Palsy: Multichannel Neuromuscular Stimulation.

Cerebral palsy (CP) is the most common childhood motor disability and often results in debilitating walking abnormalities, such as flexed-knee and stiff-knee gait. Current medical and surgical treatments are only partially effective in improving gait abnormalities and may cause significant muscle weakness. However, emerging artificial walking technologies, such as step-initiated, multichannel neuromuscular electrical stimulation (NMES), can substantially improve gait patterns and promote muscle strength in children with spastic CP. NMES may also be applied to specific lumbar-sacral sensory roots to reduce spasticity. Development of tablet computer-based multichannel NMES can leverage lightweight, wearable wireless stimulators, advanced control design, and surface electrodes to activate lower-limb muscles. Musculoskeletal models have been used to characterize muscle contributions to unimpaired gait and identify high muscle demands, which can help guide multichannel NMES-assisted gait protocols. In addition, patient-specific NMES-assisted gait protocols based on 3D gait analysis can facilitate the appropriate activation of lower-limb muscles to achieve a more functional gait: stance-phase hip and knee extension and swing-phase sequence of hip and knee flexion followed by rapid knee extension. NMES-assisted gait treatment can be conducted as either clinic-based or home-based programs. Rigorous testing of multichannel NMES-assisted gait training protocols will determine optimal treatment dosage for future clinical trials. Evidence-based outcome evaluation using 3D kinematics or temporal-spatial gait parameters will help determine immediate neuroprosthetic effects and longer term neurotherapeutic effects of step-initiated, multichannel NMES-assisted gait in children with spastic CP. Multichannel NMES is a promising assistive technology to help children with spastic CP achieve a more upright, functional gait.

Hind limb motoneurons activity during fictive locomotion or scratching induced by pinna stimulation, serotonin, or glutamic acid in brain cortex-ablated cats.

In brain cortex-ablated cats (BCAC), hind limb motoneurons activity patterns were studied during fictive locomotion (FL) or fictive scratching (FS) induced by pinna stimulation. In order to study motoneurons excitability: heteronymous monosynaptic reflex (HeMR), intracellular recording, and individual Ia afferent fiber antidromic activity (AA) were analyzed. The intraspinal cord microinjections of serotonin or glutamic acid effects were made to study their influence in FL or FS During FS, HeMR amplitude in extensor and bifunctional motoneurons increased prior to or during the respective electroneurogram (ENG). In soleus (SOL) motoneurons were reduced during the scratch cycle (SC). AA in medial gastrocnemius (MG) Ia afferent individual fibers of L6-L7 dorsal roots did not occur during FS Flexor digitorum longus (FDL) and MG motoneurons fired with doublets during the FS bursting activity, motoneuron membrane potential from some posterior biceps (PB) motoneurons exhibits a depolarization in relation to the PB (ENG). It changed to a locomotor drive potential in relation to one of the double ENG, PB bursts. In FDL and semitendinosus (ST) motoneurons, the membrane potential was depolarized during FS, but it did not change during FL Glutamic acid injected in the L3-L4 spinal cord segment favored the transition from FS to FL During FL, glutamic acid produces a duration increase of extensors ENGs. Serotonin increases the ENG amplitude in extensor motoneurons, as well as the duration of scratching episodes. It did not change the SC duration. Segregation and motoneurons excitability could be regulated by the rhythmic generator and the pattern generator of the central pattern generator.