Effects of bihemispheric transcranial direct current stimulation on motor recovery in subacute stroke patients: a double-blind, randomized sham-controlled trial.

BACKGROUND: Bihemispheric transcranial direct current stimulation (tDCS) of the primary motor cortex (M1) can simultaneously modulate bilateral corticospinal excitability and interhemispheric interaction. However, how tDCS affects subacute stroke recovery remains unclear. We investigated the effects of bihemispheric tDCS on motor recovery in subacute stroke patients. METHODS: We enrolled subacute inpatients who had first-ever ischemic stroke at subcortical regions and moderate-to-severe baseline Fugl-Meyer Assessment of Upper Extremity (FMA-UE) score 2-56. Participants between 14 and 28 days after stroke were double-blind, randomly assigned (1:1) to receive real (n = 13) or sham (n = 14) bihemispheric tDCS (with ipsilesional M1 anode and contralesional M1 cathode, 20 min, 2 mA) during task practice twice daily for 20 sessions in two weeks. Residual integrity of the ipsilesional corticospinal tract was stratified between groups. The primary efficacy outcome was the change in FMA-UE score from baseline (responder as an increase ≥ 10). The secondary measures included changes in the Action Research Arm Test (ARAT), FMA-Lower Extremity (FMA-LE) and explorative resting-state MRI functional connectivity (FC) of target regions after intervention and three months post-stroke. RESULTS: Twenty-seven participants completed the study without significant adverse effects. Nineteen patients (70%) had no recordable baseline motor-evoked potentials (MEP-negative) from the paretic forearm. Compared with the sham group, the real tDCS group showed enhanced improvement of FMA-UE after intervention (p < 0.01, effect size η2 = 0.211; responder rate: 77% vs. 36%, p = 0.031), which sustained three months post-stroke (p < 0.01), but not ARAT. Interestingly, in the MEP-negative subgroup analysis, the FMA-UE improvement remained but delayed. Additionally, the FMA-LE improvement after real tDCS was not significantly greater until three months post-stroke (p < 0.01). We found that the individual FMA-UE improvements after real tDCS were associated with bilateral intrahemispheric, rather than interhemispheric, FC strengths in the targeted cortices, while the improvements after sham tDCS were associated with predominantly ipsilesional FC changes after adjustment for age and sex (p < 0.01). CONCLUSIONS: Bihemispheric tDCS during task-oriented training may facilitate motor recovery in subacute stroke patients, even with compromised corticospinal tract integrity. Further studies are warranted for tDCS efficacy and network-specific neuromodulation. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov: (ID: NCT02731508).

Pilates-based core exercise improves health-related quality of life in people living with chronic low back pain: A pilot study.

PURPOSE: To investigate the effects of Pilates exercise on improving health-related quality of life in people living with chronic low back pain. METHODS: This was a single-blind, randomised clinical trial. Thirty-nine physically active subjects aged between 30 and 70 years with nonspecific chronic low back pain for more than three months were recruited. The study employed a pretest-posttest design, with a 4 -, 8 -, and 26-week follow-up. For eight weeks, the intervention group participated in a group-supervised, mat-based Pilates program, while the control group received the usual pharmacologic and rehabilitation standard of care, including patient education on chronic low back pain. The primary outcome was self-perceived health status measured using the EQ-5D questionnaire in a structured form and a visual analogue scale. Secondary outcomes included intensity of pain and degree of disability. RESULTS: By the end of the 8-week Pilates program, the intervention group achieved a better health-related quality of life on the EQ-5D visual analogue score than the control group. In assessing the trends in each individual group regarding pain, the intervention group demonstrated an earlier pain reduction than the control group that lasted until the end of the trial. CONCLUSIONS: An 8-week supervised Pilates-based core exercise program is an effective therapeutic modality for improving self-perceived health status in patients with chronic low back pain. This finding could inform clinicians of better alternatives when they suggest exercise interventions for chronic low back pain.

Neurophysiological signatures of hand motor response to dual-transcranial direct current stimulation in subacute stroke: a TMS and MEG study.

BACKGROUND: Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors. METHODS: We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2-4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS. RESULTS: Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS. CONCLUSIONS: Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.

ß-Oscillations Reflect Recovery of the Paretic Upper Limb in Subacute Stroke.

Background. Recovery of upper limb function post-stroke can be partly predicted by initial motor function, but the mechanisms underpinning these improvements have yet to be determined. Here, we sought to identify neural correlates of post-stroke recovery using longitudinal magnetoencephalography (MEG) assessments in subacute stroke survivors. Methods. First-ever, subcortical ischemic stroke survivors with unilateral mild to moderate hand paresis were evaluated at 3, 5, and 12 weeks after stroke using a finger-lifting task in the MEG. Cortical activity patterns in the ß-band (16-30 Hz) were compared with matched healthy controls. Results. All stroke survivors (n=22; 17 males) had improvements in action research arm test (ARAT) and Fugl-Meyer upper extremity (FM-UE) scores between 3 and 12 weeks. At 3 weeks post-stroke the peak amplitudes of the movement-related ipsilesional ß-band event-related desynchronization (ß-ERD) and synchronization (ß-ERS) in primary motor cortex (M1) were significantly lower than the healthy controls (p<0.001) and were correlated with both the FM-UE and ARAT scores (r=0.51-0.69, p<0.017). The decreased ß-ERS peak amplitudes were observed both in paretic and non-paretic hand movement particularly at 3 weeks post-stroke, suggesting a generalized disinhibition status. The peak amplitudes of ipsilesional ß-ERS at week 3 post-stroke correlated with the FM-UE score at 12 weeks (r=0.54, p=0.03) but no longer significant when controlling for the FM-UE score at 3 weeks post-stroke.Conclusions. Although early ß-band activity does not independently predict outcome at 3 months after stroke, it mirrors functional changes, giving a potential insight into the mechanisms underpinning recovery of motor function in subacute stroke.

Brain Activation and Gait Alteration During Cognitive and Motor Dual Task Walking in Stroke-A Functional Near-Infrared Spectroscopy Study.

This paper investigated the effects of cognitive and motor dual tasks on gait performance and brain activities in stroke; 23 stroke subjects performed single walking (SW), walking while performing cognitive task (WCT), and walking while performing motor task (WMT) at self-selected speed. The gait performance was recorded, including speed, cadence, stride time, stride length, and dual task cost (DTC). Brain activities in prefrontal cortex, premotor cortex (PMC), and supplementary motor areas (SMAs) were measured by functional near-infrared spectroscopy during walking. Results showed significant decrease in speed, cadence, and stride length, and increase in stride time was noted in both WCT and WMT compared with SW condition. There was no significant difference in DTC between WCT and WMT. The non-lesioned SMA and most channels of bilateral PMCs exhibited significant increases in the index of hemoglobin differential during WCT and WMT compared with SW. Moreover, gait performance was negatively correlated with bilateral PMCs and lesioned SMA during different walking tasks. In conclusion, deteriorated gait performance was noted in stroke attempting dual tasks. There is no significant difference between the two dual tasks on gait performance. Nevertheless, SMA and especially PMC were crucial in cognitive and motor dual task walking after stroke.

Functional improvement in chronic human spinal cord injury: Four years after acidic fibroblast growth factor.

Few treatments have proven effective for patients with chronic spinal cord injury (SCI). This study aimed to evaluate the efficacy and safety of acidic fibroblast growth factor (aFGF) in human SCI. This was an open-label prospective clinical trial of aFGF with an extended follow-up to 48 months. All patients were treated with aFGF 3 times, including once directly applied to the injured spinal cord during neurolysis surgery, and twice via lumbar punctures at 3- and 6-months post-operation. Every patient was evaluated with standardized measurements of neurological functions. The trial initially enrolled 60 patients (30 cervical and 30 thoracolumbar SCI), but only 46 (21 cervical- and 25 thoracolumbar-SCI) completed the follow-up. The ASIA impairment scales, motor, pin prick, light touch, and FIM motor subtotal scores were all improved in both groups, except that the ASIA scores of light touch only demonstrated tendency of increase in the cervical-SCI group. All patients had a decrease in dependence, and there were no major adverse events or other oncological problems throughout the follow-up. At 48 months, the study demonstrated that aFGF was safe, feasible, and could yield modest functional improvement in chronic SCI patients. Further randomized control investigations are warranted for validation of its optimal dosage.

Cognitive and motor dual task gait training improve dual task gait performance after stroke - A randomized controlled pilot trial.

This study investigated effects of cognitive and motor dual task gait training on dual task gait performance in stroke. Participants (n = 28) were randomly assigned to cognitive dual task gait training (CDTT), motor dual task gait training (MDTT), or conventional physical therapy (CPT) group. Participants in CDTT or MDTT group practiced the cognitive or motor tasks respectively during walking. Participants in CPT group received strengthening, balance, and gait training. The intervention was 30 min/session, 3 sessions/week for 4 weeks. Three test conditions to evaluate the training effects were single walking, walking while performing cognitive task (serial subtraction), and walking while performing motor task (tray-carrying). Parameters included gait speed, dual task cost of gait speed (DTC-speed), cadence, stride time, and stride length. After CDTT, cognitive-motor dual task gait performance (stride length and DTC-speed) was improved (p = 0.021; p = 0.015). After MDTT, motor dual task gait performance (gait speed, stride length, and DTC-speed) was improved (p = 0.008; p = 0.008; p = 0.008 respectively). It seems that CDTT improved cognitive dual task gait performance and MDTT improved motor dual task gait performance although such improvements did not reach significant group difference. Therefore, different types of dual task gait training can be adopted to enhance different dual task gait performance in stroke.

Treatment of Spinocerebellar Ataxia With Mesenchymal Stem Cells: A Phase I/IIa Clinical Study.

Ataxia is one of the most devastating symptoms of many neurodegenerative disorders. As of today, there is not any effective treatment to retard its progression. Mesenchymal stem cells (MSCs) have shown promise in treating neurodegenerative diseases. We hereby report the results of a phase I/IIa clinical study conducted in Taiwan to primarily evaluate the safety, tolerability, and, secondarily, the possible efficacy of intravenous administration of allogeneic adipose tissue-derived MSCs from healthy donors. Six patients with spinocerebellar ataxia type 3 and one with multiple system atrophy-cerebellar type were included in this open-label study with intravenous administration of 106 cells/kg body weight. The subjects were closely monitored for 1 year for safety (vital signs, complete blood counts, serum biochemical profiles, and urinalysis) and possible efficacy (scale for assessment and rating of ataxia and sensory organization testing scores, metabolite ratios on the brain magnetic resonance spectroscopy, and brain glucose metabolism of 18-fluorodeoxyglucose using positron emission tomography). No adverse events related to the injection of MSCs during the 1-year follow-up were observed. The intravenous administration of allogeneic MSCs seemed well tolerated. Upon study completion, all patients wished to continue treatment with the allogeneic MSCs. We conclude that allogeneic MSCs given by intravenous injection seems to be safe and tolerable in patients with spinocerebellar ataxia type 3, thus supporting advancement of the clinical development of allogeneic MSCs for the treatment of spinocerebellar ataxias (SCAs) in a randomized, double-blind, placebo-controlled phase II trials.

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.

The influence of shoulder pain on functional limitation, perceived health, and depressive mood in patients with traumatic paraplegia.

OBJECTIVE: To assess whether functional activity, perceived health, and depressive symptoms differ between individuals with traumatic paraplegia with and without shoulder pain. DESIGN: Cross sectional and comparative investigation using the unified questionnaire. SETTING: Neural Regeneration and Repair Division unit of Taipei Veterans General Hospital in Taiwan. PARTICIPANTS: Seventy-six patients with paraplegia (23 with and 53 without shoulder pain) who had experienced spinal cord injury at American Spinal Injury Association Impairment Scale T2 to T12 neurologic level (at least 6 months previously). OUTCOME MEASURES: Spinal Cord Independence Measure (SCIM), a single item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Patient Health Questionnaire-9 (PHQ-9) depression scale. RESULTS: Shoulder pain was prevalent in 30% patients. Patients with shoulder pain had significantly worse perceived health and greater depressive symptoms than those without. No significant difference was found in functional ability between groups. Greater shoulder pain intensity was related to higher depressive scores (r=0.278, P=0.017) and lower self-perceived health scores (r=-0.433, P<0.001) but not SCIM scores (P=0.342). CONCLUSION: Although shoulder pain was unrelated to functional limitation, it was associated with lower perceived health and higher depressive mood levels.

Long-term sacral magnetic stimulation for refractory stress urinary incontinence.

OBJECTIVE: To evaluate the effects of sacral magnetic stimulation (SMS) on functional and urodynamic improvement in patients with refractory stress urinary incontinence (SUI). DESIGN: A sham-controlled, double-blind, parallel study design with a 4.5-month follow-up. SETTING: A tertiary hospital. PARTICIPANTS: Women (age, 45-75y) with SUI refractory to first-line management (N=34) were allocated to either an experimental (n=20) group or a sham (n=14) group. INTERVENTIONS: The SMS protocol consisted of 5-Hz, 20-minute treatments administered over the bilateral third sacral roots, with the intensity set at approximately 70% of the maximal output, for 12 consecutive weekdays. MAIN OUTCOME MEASURES: Urodynamic assessments and 2 life stress questionnaires, namely, the Urge-Urinary Distress Inventory (U-UDI) and the Overactive Bladder Questionnaire (OAB-q), were administered pre- and post-SMS intervention. We administered the U-UDI (primary outcome measure) and the OAB-q at 3-week intervals during the follow-up period until 18 weeks after the final intervention. RESULTS: The experimental group exhibited significant improvements in both U-UDI and OAB-q scores postintervention (P=.011-.014) and at follow-up visits (P<.001-.007) compared with the sham group. In addition, significant increases in bladder capacity, urethral functional length, and the pressure transmission ratio (P=.009-.033) were noted postintervention. Multivariate regression analysis revealed that patients with more severe symptoms benefited more from SMS. A poorer baseline U-UDI score and a shorter urethral functional length were associated with a greater response to SMS. CONCLUSIONS: Our observations of a greater response to SMS in patients with more severe SUI than in those with mild symptoms, as well as the long-term benefits of the treatment, confirm the efficacy of SMS in treating SUI.

Repairing the ventral root is sufficient for simultaneous motor and sensory recovery in multiple complete cervical root transection injuries.

AIM: In multiple cervical root transection injuries, motor and sensory recovery has been demonstrated after repairing both dorsal and ventral roots with autologous grafts applied to the dorsal and ventral aspects, respectively. However, in clinical situations, autologous grafts may not be sufficient to repair both roots in this situation. In this study, the authors evaluated whether repairing ventral root alone is sufficient for simultaneous sensory and motor function recovery. MAIN METHODS: In the transected group, the left 6th-8th cervical roots were pulled and transected at the spinal cord junction. In the repair group, the transected root was anastomosed to a single autologous nerve graft, which was inserted into the ventral horn through a pial incision. Acidic fibroblast growth factor mixed with fibrin glue was applied to the surgical area. Motor function, sensory function, cortical somatosensory evoked potentials (SSEPs), axon tracing, and CGRP(+) fibers were evaluated. KEY FINDINGS: The repaired rats exhibited simultaneous sensory and motor function recovery. At the 16th weeks, SSEPs reappeared in all animals of the repair group, but not in the transected group. Retrograde axon tracing demonstrated an increased number of sensory neurons in the dorsal root ganglia and regenerating nerve fibers in the dorsal horn. CGRP(+) fibers were significantly increased in the repair group and restricted to laminae I and II. SIGNIFICANCE: This is the first report that in multiple root avulsions with insufficient grafts, repairing ventral roots alone leads to both sensory recovery and motor recovery. This finding may help patients with multiple cervical root avulsions.

Quantitative measures of functional outcomes and quality of life in patients with C5 palsy.

BACKGROUND: It is generally understood that postoperative C5 palsy can occur with anterior or posterior decompression surgery, but functional measures of the palsy have not been well documented. This study aimed to investigate the incidence of C5 palsy in different surgical procedures, examine the correlations between muscle strength, upper extremity functional measures, and health-related quality of life, and to observe potential risk factors contributing to C5 palsy. METHODS: Our investigation involved a retrospective study design. A total of 364 patients who underwent decompression surgery were indicated within the selected exclusion criteria. Additionally, 12 C5 palsy patients were recruited. The relationships between the manual muscle test (MMT), the action research arm test (ARAT), the Jebsen test of hand function (JTHF), and the European quality of life-5 dimensions (EQ-5D) were studied, and univariate analyses were performed to search possible risk factors and recovery investigation. RESULTS: The data analyzed in the 12 cases and C5 palsy incidences (3.3%) were: 0.7% in anterior procedures (n = 2), 8.8% in posterior procedures (n = 6), and 36.4% in combined procedures (n = 4). Moderate-to-high correlations were observed between the ARAT, JTHF, EQ-5D visual analog scale scores, and MMT (r = 0.636-0.899). There were significant differences in patient age, etiology of cervical lesion, variable decompression procedures, and the number of decompression levels between the C5 palsy and non-C5 palsy groups. For female patients (p = 0.018) and number of decompression levels (p = 0.028), there were significant differences between the complete recovery and the incomplete recovery groups. CONCLUSION: Patients undergoing combined anterior-posterior decompression surgery had the highest incidence of C5 palsy, and correlations between the ARAT, JTHF, EQ-5D visual analog scale clinical tools, and MMT scores supported these findings. Female status and lower decompression levels could also be predictive factors for complete recovery, although additional research is needed to substantiate these findings.

Intermittent theta burst stimulation over ipsilesional primary motor cortex of subacute ischemic stroke patients: a pilot study.

BACKGROUND: We demonstrated that prolonged transcranial magnetic intermittent theta burst stimulation (iTBS, 1200 pulses/session=iTBS1200) produces longer-lasting facilitation in corticospinal excitability than ordinary form of iTBS in healthy subjects. OBJECTIVE: Here we show the safety and small-scale efficacy of iTBS1200 over ipsilesional primary motor cortex (M1) in subacute stroke patients. METHODS: Twelve patients with first-time, subacute ischemic stroke of the middle cerebral artery were randomized into two groups that received 10 daily-sessions of either iTBS1200 or sham stimulation (n=6/group) over ipsilesional M1 hand region in addition to medical and rehabilitation treatments. The primary outcome measures were safety and tolerability. The secondary outcome measures included the National Institute of Health Stroke Scale (NIHSS), Upper Extremity Fugl-Meyer Test (UE-FMT), Action Research Arm Test (ARAT), active motor thresholds (aMTs)/motor-evoked potentials (MEPs) from the extensor carpi radialis (ECR), and magnetoencephalography on post-intervention day 1 and post-stroke day 60. RESULTS: iTBS or sham stimulation was well tolerated by all patients without seizures or significant adverse effects. Compared with the matched controls, the iTBS group showed measurable improvements in the NIHSS and the proximal UE-FMT scores on post-intervention day 1 and post-stroke day 60. Nevertheless, the hand ARAT scores, aMT and MEPs from the paretic ECR were not different between groups. Post-movement beta synchronization increased over iTBS-conditioned M1 on post-intervention day 1 in testable patients. CONCLUSIONS: Repetitive sessions of iTBS1200 over ipsilesional M1 of subacute stroke patients are safe and the potential benefits encourage a larger trial to determine the efficacy in stroke patients. (ClinicalTrials.gov: NCT-01323881).

Effects of intravascular laser irradiation of blood in mitochondria dysfunction and oxidative stress in adults with chronic spinal cord injury.

OBJECTIVE: This study investigated the clinical effects of intravascular laser irradiation of blood (ILIB) therapy on oxidative stress and mitochondrial dysfunction in subjects with chronic spinal cord injury (SCI) resulting from trauma. BACKGROUND DATA: Little is known about how ILIB may generate antioxidant defenses in humans, and there is still a lack of randomized, sham-control studies to indicate its influence on different metabolic pathways. METHODS: Twenty-four chronic SCI subjects (assigned to a sham and a study group), and 12 normal subjects were recruited. The study group underwent 1 h daily of ILIB for 15 days over 3 weeks. The sham group underwent ILIB with no laser power. RESULTS: Baseline measurements established higher oxidative stress and mitochondrial dysfunction in the SCI subjects than in the normal subjects. At day 15 of therapy, the study group revealed a significantly higher mitochondrial DNA (mtDNA) copy number, white blood cell adenosine triphosphate (WBC ATP) synthesis, and total antioxidant capacity (TAC) with significantly reduced malondialdehyde (MDA), than did the sham group. The study group intragroup comparison revealed significantly increased mtDNA copy numbers, WBC ATP synthesis, and TAC, with significantly reduced MDA, compared with its baseline measurements. The sham group intragroup comparisons demonstrated no statistical differences. Low-density lipoprotein (LDL) in the study group was significantly reduced at days 10 and 15, with significantly higher high-density lipoprotein (HDL) at day 45. CONCLUSIONS: Our study results contribute to the knowledge about the effectiveness of ILIB in alleviating oxidative stress and mitochondrial dysfunction in chronic SCI patients.

Prevalence, characteristics, and work-related risk factors of low back pain among hospital nurses in Taiwan: a cross-sectional survey.

BACKGROUND: Low back pain is a common health problem among hospital nurses. However, the prevalence, characteristics, and work-related risk factors of low back pain have not been widely investigated in Taiwan. MATERIALS AND METHODS: This study used a cross-sectional survey of 217 hospital nurses to gather self-reported information on the prevalence of back pain, demographic and pain characteristics, and work-related risk factors from 178 respondents who indicated a past history of back pain. The association between the characteristics of back pain and work-related risk factors was also examined. RESULTS: The lifetime prevalence of back pain was 82.03%, and the point prevalence of back pain was 43.78%. The mean pain score is 41.67. The number of years at work was significantly associated with the pain score for an individual's most recent episode of back pain, the extent of bothersomeness of back pain and leg pain, and the extent to which back pain interfered with normal work. CONCLUSION: Back pain is common among hospital nurses in Taiwan. Years at work are significantly associated with pain severity and disability caused by back pain.

Acidic fibroblast growth factor for repair of human spinal cord injury: a clinical trial.

OBJECT: The study aimed to verify the safety and feasibility of applying acidic fibroblast growth factor (aFGF) with fibrin glue in combination with surgical neurolysis for nonacute spinal cord injury. METHODS: This open-label, prospective, uncontrolled human clinical trial recruited 60 patients with spinal cord injuries (30 cervical and 30 thoracolumbar). The mean patient age was 36.5 ± 15.33 (mean ± SD) years, and the male/female ratio was 3:1. The mean time from injury to treatment was 25.7 ± 26.58 months, and the cause of injury included motor vehicle accident (26 patients [43.3%]), fall from a height (17 patients [28.3%]), sports (4 patients [6.7%]), and other (13 patients [21.7%]). Application of aFGF with fibrin glue and duraplasty was performed via laminectomy, and an adjuvant booster of combined aFGF and fibrin glue (2 ml) was given at 3 and 6 months postsurgery via lumbar puncture. Outcome measurements included the American Spinal Injury Association (ASIA) motor scores, sensory scores, impairment scales, and neurological levels. Examination of functional independence measures, visual analog scale, MR imaging, electrophysiological and urodynamic studies, hematology and biochemistry tests, tumor markers, and serum inflammatory cytokines were all conducted. All adverse events were monitored and reported. Exclusions were based on refusal, unrelated adverse events, or failure to participate in the planned rehabilitation. RESULTS: Forty-nine patients (26 with cervical and 23 with thoracolumbar injuries) completed the 24-month trial. Compared with preoperative conditions, the 24-month postoperative ASIA motor scores improved significantly in the cervical group (from 27.6 ± 15.55 to 37.0 ± 19.93, p < 0.001) and thoracolumbar group (from 56.8 ± 9.21 to 60.7 ± 10.10, p < 0.001). The ASIA sensory scores also demonstrated significant improvement in light touch and pinprick in both groups: from 55.8 ± 24.89 to 59.8 ± 26.47 (p = 0.049) and 56.3 ± 23.36 to 62.3 ± 24.87 (p = 0.003), respectively, in the cervical group and from 75.7 ± 15.65 to 79.2 ± 15.81 (p < 0.001) and 78.2 ± 14.72 to 82.7 ± 16.60 (p < 0.001), respectively, in the thoracolumbar group. At 24-month follow-up, the ASIA impairment scale improved significantly in both groups (30% cervical [p = 0.011] and 30% thoracolumbar [p = 0.003]). There was also significant improvement in neurological level in the cervical (from 5.17 ± 1.60 to 6.27 ± 3.27, p = 0.022) and thoracolumbar (from 18.03 ± 4.19 to 18.67 ± 3.96, p = 0.001) groups. The average sum of motor items in functional independence measure also had significant improvement in both groups (p < 0.05). The walking/wheelchair locomotion subscale showed increased percentages of patients who were ambulatory (from 3.4% to 13.8% and from 17.9% to 35.7% in the cervical and thoracolumbar groups, respectively). There were no related adverse events. CONCLUSIONS: The use of aFGF for spinal cord injury was safe and feasible in the present trial. There were significant improvements in ASIA motor and sensory scale scores, ASIA impairment scales, neurological levels, and functional independence measure at 24 months after treatment. Further large-scale, randomized, and controlled investigations are warranted to evaluate the efficacy and long-term results.

Intermittent θ burst stimulation over primary motor cortex enhances movement-related ß synchronisation.

OBJECTIVE: The objective of this study is to investigate how transcranial magnetic intermittent theta burst stimulation (iTBS) with a prolonged protocol affects human cortical excitability and movement-related oscillations. METHODS: Using motor-evoked potentials (MEPs) and movement-related magnetoencephalography (MEG), we assessed the changes of corticospinal excitability and cortical oscillations after iTBS with double the conventional stimulation time (1200 pulses, iTBS1200) over the primary motor cortex (M1) in 10 healthy subjects. Continuous TBS (cTBS1200) and sham stimulation served as controls. RESULTS: iTBS1200 facilitated MEPs evoked from the conditioned M1, while inhibiting MEPs from the contralateral M1 for 30 min. By contrast, cTBS1200 inhibited MEPs from the conditioned M1. Importantly, empirical mode decomposition-based MEG analysis showed that the amplitude of post-movement beta synchronisation (16-26 Hz) was significantly increased by iTBS1200 at the conditioned M1, but was suppressed at the nonconditioned M1. Alpha (8-13 Hz) and low gamma-ranged (35-45 Hz) rhythms were not notably affected. Movement kinetics remained consistent throughout. CONCLUSIONS: TBS1200 modulated corticospinal excitability in parallel with the direction of conventional paradigms with modestly prolonged efficacy. Moreover, iTBS1200 increased post-movement beta synchronisation of the stimulated M1, and decreased that of the contralateral M1, probably through interhemispheric interaction. SIGNIFICANCE: Our results provide insight into the underlying mechanism of TBS and reinforce the connection between movement-related beta synchronisation and corticospinal output.

A novel strategy for repairing preganglionic cervical root avulsion in brachial plexus injury by sural nerve grafting.

OBJECT: In this study, the authors evaluated the efficacy of a new surgical strategy for reconnecting the injured brachial plexus with the spinal cord using fibrin glue containing acidic fibroblast growth factor as an adhesive and neurotrophic agent. METHODS: Eighteen patients with preganglionic brachial plexus injuries, each with varying degrees of upper limb dysfunction, underwent cervical laminectomy with or without sural nerve grafting. The treatment of each avulsed root varied according to the severity of the injury. Some patients also underwent a second-stage operation involving supraclavicular brachial plexus exploration for reconnection with the corresponding segment of cervical spinal cord at the trunk level. Muscle strength was graded both pre- and postoperatively with the British Medical Research Council scale, and the results were analyzed with the Friedman and Wilcoxon signed-rank tests. RESULTS: Muscle strength improvements were observed in 16 of the 18 patients after 24 months of follow-up. Significant improvements in mean muscle strength were observed in patients from all repair method groups at 12 and 24 months postoperatively (p < 0.05). Statistical significance was not reached in the groups with insufficient numbers of cases. CONCLUSIONS: The authors' new surgical strategy yielded clinical improvement in muscle strength after preganglionic brachial plexus injury, such that nerve regeneration may have taken place. Reconnection of the brachial plexus to the cervical spinal cord is possible. Functional motor recovery, observed through increases in Medical Research Council-rated muscle strength in the affected arm, is likewise possible.

Nerve repair using acidic fibroblast growth factor in human cervical spinal cord injury: a preliminary Phase I clinical study.

OBJECT: The aim of this study was to assess functional outcomes of nerve repair using acidic fibroblast growth factor (FGF) in patients with cervical spinal cord injury (SCI). METHODS: Nine patients who had cervical SCI for longer than 5 months were included in pre- and postoperative assessments of their neurological function. The assessments included evaluating activities of daily living, associated functional ability, and degree of spasticity, motor power, sensation, and pain perception. After the first set of assessments, the authors repaired the injured segment of the spinal cord using a total laminectomy followed by the application of fibrin glue containing acidic FGF. Clinical evaluations were conducted 1, 2, 3, 4, 5, and 6 months after the surgery. Preoperative versus postoperative differences in injury severity and grading of key muscle power and sensory points were calculated using the Wilcoxon signed-rank test. RESULTS: The preoperative degree of injury severity, as measured using the American Spinal Injury Association (ASIA) scoring system, showed that preoperative motor (52.4 +/- 25.9 vs 68.6 +/- 21.5), pinprick (61.0 +/- 34.9 vs 71.6 +/- 31.0), and light touch scores (57.3 +/- 33.9 vs 71.9 +/- 30.2) were significantly lower than the respective postoperative scores measured 6 months after surgery (p = 0.005, 0.012, and 0.008, respectively). CONCLUSIONS: Based on the significant difference in ASIA motor and sensory scale scores between the preoperative status and the 6-month postoperative follow-up, this novel nerve repair strategy of using acidic FGF may have a role in the repair of human cervical SCI. Modest nerve regeneration occurred in all 9 patients after this procedure without any observed adverse effects. This repair strategy thus deserves further investigation, clinical consideration, and refinement.