Pilot Study on Therapeutic Horticulture for Chronic Low Back Pain: A Mixed Methods Study.

Background: Chronic low back pain (LBP) is common and associated with disability worldwide. Therapists trained in Therapeutic Horticulture (TH) use gardening activities and proximity to nature for therapy and rehabilitation. Patients seeking care for LBP would benefit physically and psychologically from participating in TH. Primary study objectives: The first aim of this study was to determine if and which patients who were receiving care for chronic LBP were interested in TH to help manage their pain. The second aim of the project was to quantify changes in LBP, functional tasks and anxiety upon completion of a TH session in patients with LBP. Methods/Design: This was a 2-part study with a mixed methods design: the cross-sectional survey Group and the pilot experimental Group. The Cross-sectional Survey component comprised a total of 170 patients; age 55.9±17.3 years; 58% women. The Pilot Experimental component comprised a total of 9 patients; age 48±14.7 years; 78% women. Participants Cross-sectional component: Patients receiving medical care for LBP with or without additional joint pain sites (n=170; age 55.9 ± 17.3 years; 58% women. Participants Pilot experimental component: A total of 9 patients (7 women); mean age 48 ± 14.7 years and mean duration of back pain 12.6 ± 8.1 years. Setting: Patients were receiving medical care at the University of Florida Health Comprehensive Spine Center in the United States, in the tertiary care health system. Intervention: 1-hour TH session that involved trained therapists using propagating and harvesting herbs planted at various heights in an outdoor setting for therapy and rehabilitation. Primary outcome measures: A therapeutic horticulture interest survey, PROMIS Pain Interference and Physical Function scores, functional tests (timed-get-up-and-go [TUG], spine range of motion), Roland Morris Disability Questionnaire (RMDQ), 11-point Numerical Pain Rating Scale (NRSpain), 10-item PROMIS Global Health Questionnaire, Tampa Scale of Kinesiophobia-11 and patient enjoyment. Results: Cross-sectional survey component: A total of 2% of patients had not previously heard of TH and 68% were interested in learning more about it. Patients who expressed interest in TH reported a higher level of agreement that TH could improve mood, improve muscle strength, lower stress level, increase movement and enable patients to perform self-care activities with less pain (all P < .001). PROMIS Pain Interference and Physical Function scores did not differ by interest in TH (P > .05). Pilot Experimental component: In the pilot session, 44% reported using pain medication to manage their low back pain and 66% believed gardening could provide pain relief. Improvements were observed in anxiety (55.3%; P =.017), spine flexion (31.4%; P =.003) and spine rotation to the left (26.7%; P =.005). All participants believed that gardening improved overall health and spine motion while reducing low back pain. All patients reported having gardening experience at home and none had TH experience. Conclusion: Patients presenting to an outpatient spine clinic may be receptive to trying TH in conjunction with or in place of conventional medicine to promote health and well-being. The pilot experimental group data suggested that acute TH is enjoyable and may confer the benefits of reducing anxiety and improving spine motion. Future larger studies could use different dose response approaches, explore different TH activity types and involve participants from different geographic locations while controlling for LBP history and psychological status.

Acute and chronic cardiovascular responses to concentric and eccentric exercise in older adults with knee osteoarthritis.

PURPOSE: Muscle contraction type in resistance exercise training may confer benefits besides strength in individuals with osteoarthritis and cardiovascular disease (CVD) risks. The purpose of the study was to explore whether Eccentric-resistance training (RT) improved hemodynamic responses to acute walking exercise stress compared to Concentric-RT among individuals with knee OA over four months. METHODS: This was a secondary analysis from a randomized, controlled, single-blinded study. Participants (N = 88; 68.3 ± 6.4 yrs; 67.4% female) were randomized to one of two work-matched resistance training (RT) programs against a non-RT control group. Pre-training and month four, participants completed a self-paced Six-Minute Walk Test (6MWT) and progressive treadmill exercise test. Heart rates, blood pressures and mean arterial pressures (MAP) were captured during each test. Antihypertensive medications use was documented at each time point. RESULTS: Leg strength improved in both training groups by month four (p < .05). Changes in 6MWT distance and progressive treadmill test time were not different across groups over four months. Neither Concentric or Eccentric RT produced different hemodyamic responses during the 6MWT compared to the control group post-training. However, Concentric RT was associated with 6.0%-7.4% reductions in systolic blood pressure during the graded treadmill walking test at 50%, 75% and 100% of the test time compared to Eccentric RT and the controls (p = .045). MAP values were lower at 75% and 100% of the treadmill test after Concentric RT (5.7%-6.0% reductions) compared to Eccentric RT (1.0%-2.4% reductions) and controls (1.5% and 4.0% elevations) post-training (p = .024). Antihypertensive medication use did not change in any group. CONCLUSIONS: The repeated, progressive exposures of Concentric RT-induced blunted the hypertensive responses to acute exercise compared to Eccentric-RT. Among people with knee OA, Concentric-RT may confer strength benefits to manage OA and possibly reduce cardiovascular stress during exercise.

Telerehabilitation service impact on physical function and adherence compared to face-to-face rehabilitation in patients with stroke: A systematic review and meta-analysis.

OBJECTIVES: The purposes of this systematic review and meta-analysis were to (1) appraise the available evidence of telerehabilitation program effects on functional outcomes, adherence, and patient satisfaction compared to face-to-face programs after stroke; and (2) provide direction for future outcome measure selection and development for clinical research purposes. TYPE: Systematic review and meta analysis of randomized controlled trials. LITERATURE SURVEY: MEDLINE, CINAHL, Embase, Scopus, Proquest Theses and Dissertations, Physiotherapy Evidence Database (PEDro), and Clinicaltrials.gov were searched for studies published in English from 1964 to the end of April 2022. METHODOLOGY: A total of 6450 studies were identified, 13 were included in the systematic review, and 10 with at least 3 reported similar outcomes were included the meta-analysis. Methodological quality of results was evaluated using the PEDro checklist. SYNTHESIS: Telerehabilitation demonstrated equivalency in outcomes across several domains and was favored compared to conventional face to face alone or when paired with semisupervised physical therapy on Wolf Motor Function performance score (mean difference [MD] 1.69 points, 95% confidence interval [CI] 0.21-3.17) and time score (MD 2.07 seconds, 95% CI -4.04 to -0.10, Q test = 30.27, p < .001, I2 = 93%), and Functional Mobility Assessment in the upper extremities (MD 3.32 points, 95% CI 0.90-5.74, Q test = 5.60, p = .23, I2 = 29% alone or when paired with semisupervised physical therapy). The Barthel Index participation measures of function demonstrated improvement (MD 4.18 points, 95% CI, 1.79-6.57, Q test = 3.56, p = .31, I2 = 16%). Over half of summarized study ratings were determined to be of good to excellent quality (PEDro score 6.6 ± 2.3 points). Adherence varied in available studies from 75%-100%. Satisfaction levels of telerehabilitation were highly variable. CONCLUSIONS: Telerehabilitation can improve functional outcomes and promote therapy adherence after stroke. Therapy protocols and functional assessments need substantial refinement and standardization to improve interpretation and clinical outcomes.

Anxiety state impact on recovery of runners with lower extremity injuries.

This prospective cohort study examined the impact of high anxiety levels on psychological state and gait performance during recovery in runners with lower body injuries. Recreational runners diagnosed with lower body injuries who had reduced running volume (N = 41) were stratified into groups using State Trait Anxiety Inventory (STAI) scores: high anxiety (H-Anx; STAI ≥40 points) and low anxiety (L-Anx; STAI <40 points). Runners were followed through rehabilitation to return-to-run using monthly surveys. Main outcome measures included kinesiophobia (Tampa Scale of Kinesiophobia, TSK-11), Positive and Negative Affect Schedule (PANAS; Positive and negative scores), Lower Extremity Function Scale (LEFS), running recovery (University of Wisconsin Running Injury and Recovery Index [UWRI]) and CDC Healthy Days modules for general health, days of anxiety/tension, disrupted sleep and work/usual activities. Running biomechanics were assessed at baseline and the final visit using 3D motion capture and a force-plated treadmill. The time to return-to-running for was 5.0±3.1 and 7.9±4.1 months for L-Anx and H-Anx, respectively and participants who withdrew (n = 15) did so at 7.7±6.2 months. L-Anx maintained low anxiety and H-Anx reduced anxiety from baseline to final visit (STAI = 31.5 to 28.4 points, 50.4 to 37.8 points, respectively), whereas the withdrawn runners remained clinically anxious at their final survey (41.5 to 40.3 points; p < .05). Group by time interactions were found for PANAS positive, LEFS UWRI, general health scores, and days feeling worry, tension and anxiety (all p < .05). Final running performance in L-Anx compared to H-Anx was most improved with cadence (8.6% vs 3.5%; p = .044), impact loading rate [-1.9% vs +8.9%] and lower body stiffness [+14.1% vs +3.2%; all p < .05). High anxiety may identify runners who will experience a longer recovery process, health-related functional disruptions, and less optimization of gait biomechanics during rehabilitation after a lower extremity injury.

Gait parameters, functional performance and physical activity in active and inactive Juvenile Idiopathic Arthritis.

BACKGROUND: Children with Juvenile Idiopathic Arthritis (JIA) may adopt different movement patterns and participate in physical activity during different states of disease. RESEARCH QUESTION: Which specific features of gait and physical function performance differ among children with active or inactive JIA compared to healthy children? METHODS: Forty-three children participated (14.5 ± 4.2 yrs; 60 % female). 3D-motion analysis methods were coupled with force measures from an instrumented treadmill captured gait mechanical measures. The 30-second Chair Rise Test (repetitions) and stair ascent-descent tests were performed, and the 11-point Wong-Baker face scale assessed pain after each test. RESULTS: Compared to healthy controls children with active and inactive JIA had worse outcomes (12-21 % slower self-selected and fast walking speeds, 28-34 % slower stair navigation times, 28 % fewer chair rise repetitions in 30 s; all p < .05). Children with active JIA had 8-13 % slower gait speeds, 4 % fewer chair rise repetitions and 14-16 % slower stair navigation times. At faster walking speed, children with active JIA had less hip joint flexion/extension excursion in the sagittal plane during the gait cycle, produced higher leg stiffness, and demonstrated greater interlimb asymmetry in GRF vertical impulse during loading than healthy children (all p < .05). The Pedi-FABS subscore of "Duration: performing athletic activity for as long as you would like without stopping" was rated lower in children with active JIA compared to controls (p < .05). CONCLUSION: Gait speed, specific load-bearing functional tasks and leg stiffness features of gait may be informative 'functional biomarkers' for assessing JIA burden and tracking treatment efficacy. Additional prospective studies are needed to determine how these features change over time with pain change, and understand impact on quality of life and physical activity participation.

The relationships of kinesiophobia and physical function and physical activity level in juvenile idiopathic arthritis.

BACKGROUND: Kinesiophobia may hinder physical performance measures and functional quality of life in children with juvenile idiopathic arthritis (JIA). This study aims to quantify differences in physical function in patients with JIA compared to healthy controls, and determine the effects of kinesiophobia on physical function and physical activity. METHODS: This was a comparative study of participants with JIA and healthy controls (JIA n = 26, control n = 17). All children with JIA had lower extremity joint involvement. Performance-based measures included gait speed, chair and stair navigation performance. Self-reported measures included Patient Reported Outcome Measurement Information System (PROMIS®) Physical Function Mobility, and Pain Interference and the Pediatric Functional Activity Brief Scale (Pedi-FABS). The Tampa Scale of Kinesiophobia (TSK-11) assessed patient fear of movement due to pain. Linear regression models were used to determine the contribution of TSK-11 scores on performance test and Pedi-FABS scores. RESULTS: Gait speeds were 11-15% slower, chair rise repetitions were 28% fewer, and stair ascent and descent times were 26-31% slower in JIA than controls (p < .05). PROMIS® Physical Function Mobility scores were 10% lower and Pain Interference scores were 2.6 times higher in JIA than healthy controls (p = .003). TSK-11 scores were higher in JIA than controls (p < .0001). After controlling for covariates, TSK-11 scores explained 11.7-26.5% of the variance of regression models for stair climb time, chair rise performance and Pedi-FABS scores (p < .05). CONCLUSIONS: Children with JIA experience difficulty with tasks related to body transfers. Kinesiophobia is a significant contributor to the functional task performance and may impact clinical outcomes.

How soon can we identify at-risk patients: examining initial depressive symptomology and opioid use in musculoskeletal trauma survivors?

OBJECTIVES: This study evaluates the associations between post injury depressive symptomology and opioid use from the initial time of injury in orthopedic trauma patients without pre-existing psychiatric conditions. DESIGN AND SETTING: This is a prospective study following the development of symptoms after orthopedic trauma injury conducted at a Level-1 trauma center. PATIENTS: Orthopedic trauma patients (N=96; 43.4±16.5 yrs, 40.6% women) MAIN OUTCOME MEASURES AND ANALYSIS METHODS: Beck Depression Inventory (BDI-II) was administered during index hospitalization and at 2-weeks, 6-weeks, and 3- months, and 6-months. In-hospital and out-patient opioid use were tracked. Regression analyses determined the relationship of opioid use and depressive symptoms during follow-up. RESULTS: Twenty percent of patients had moderate depressive symptom levels (BDI 20-28 points) and 11% had severe depressive symptom levels (BDI ≥29) at the time of their index hospitalization. Inpatient BDI-II depressive symptom severity levels were significantly related to depressive symptomology at 2 -weeks, 6 -weeks, and 3 -months. In-hospital or discharge opioid dose was not associated with initial or persistent depressive symptomology. Patients with persistent opioid use at 6 weeks had higher depressive symptoms six months following post-discharge than those who ceased opioid use by 6 -weeks post-discharge. CONCLUSIONS: This study suggests that depressive symptomology immediately following musculoskeletal trauma is predictive for persistent depressive symptomology in a subset of our patient population. Inpatient BDI-II depressive symptom severity levels in the hospital were significantly related to BDI-II at 2-weeks, 6-weeks, and 3-months, and persistent opioid use, past 6-weeks, was independently associated with prolonged depressive symptomology as well. Further study into effective treatment and monitoring of mental health disturbances following trauma is needed, particularly in patients with continued need for and use of opioids after discharge.

Can an Integrative Care Approach Improve Physical Function Trajectories after Orthopaedic Trauma? A Randomized Controlled Trial.

BACKGROUND: Orthopaedic trauma patients frequently experience mobility impairment, fear-related issues, self-care difficulties, and work-related disability []. Recovery from trauma-related injuries is dependent upon injury severity as well as psychosocial factors []. However, traditional treatments do not integrate psychosocial and early mobilization to promote improved function, and they fail to provide a satisfying patient experience. QUESTIONS/PURPOSES: We sought to determine (1) whether an early psychosocial intervention (integrative care with movement) among patients with orthopaedic trauma improved objective physical function outcomes during recovery compared with usual care, and (2) whether an integrative care approach with orthopaedic trauma patients improved patient-reported physical function outcomes during recovery compared with usual care. METHODS: Between November 2015 and February 2017, 1133 patients were admitted to one hospital as orthopaedic trauma alerts to the care of the three orthopaedic trauma surgeons involved in the study. Patients with severe or multiple orthopaedic trauma requiring one or more surgical procedures were identified by our orthopaedic trauma surgeons and approached by study staff for enrollment in the study. Patients were between 18 years and 85 years of age. We excluded individuals outside of the age range; those with diagnosis of a traumatic brain injury []; those who were unable to communicate effectively (for example, at a level where self-report measures could not be answered completely); patients currently using psychotropic medications; or those who had psychotic, suicidal, or homicidal ideations at time of study enrollment. A total of 112 orthopaedic trauma patients were randomized to treatment groups (integrative and usual care), with 13 withdrawn (n = 99; 58% men; mean age 44 years ± 17 years). Data was collected at the following time points: baseline (acute hospitalization), 6 weeks, 3 months, 6 months, and at 1 year. By 1-year follow-up, we had a 75% loss to follow-up. Because our data showed no difference in the trajectories of these outcomes during the first few months of recovery, it is highly unlikely that any differences would appear months after 6 months. Therefore, analyses are presented for the 6-month follow-up time window. Integrative care consisted of usual trauma care plus additional resources, connections to services, as well as psychosocial and movement strategies to help patients recover. Physical function was measured objectively (handgrip strength, active joint ROM, and Lower Extremity Gain Scale) and subjectively (Patient-Reported Outcomes Measurement Information System-Physical Function [PROMIS®-PF] and Tampa Scale of Kinesiophobia). Higher values for hand grip, Lower Extremity Gain Scale (score range 0-27), and PROMIS®-PF (population norm = 50) are indicative of higher functional ability. Lower Tampa Scale of Kinesiophobia (score range 11-44) scores indicate less fear of movement. Trajectories of these measures were determined across time points. RESULTS: We found no differences at 6 months follow-up between usual care and integrative care in terms of handgrip strength (right handgrip strength ß = -0.0792 [95% confidence interval -0.292 to 0.133]; p = 0.46; left handgrip strength ß = -0.133 [95% CI -0.384 to 0.119]; p = 0.30), or Lower Extremity Gain Scale score (ß = -0.0303 [95% CI -0.191 to 0.131]; p = 0.71). The only differences between usual care and integrative care in active ROM achieved by final follow-up within the involved extremity was noted in elbow flexion, with usual care group 20° ± 10° less than integrative care (t [27] = -2.06; p = 0.05). Patients treated with usual care and integrative care showed the same Tampa Scale of Kinesiophobia score trajectories (ß = 0.0155 [95% CI -0.123 to 0.154]; p = 0.83). CONCLUSION: Our early psychosocial intervention did not change the trajectory of physical function recovery compared with usual care. Although this specific intervention did not alter recovery trajectories, these interventions should not be abandoned because the greatest gains in function occur early in recovery after trauma, which is the key time in transition to home. More work is needed to identify ways to capitalize on improvements earlier within the recovery process to facilitate functional gains and combat psychosocial barriers to recovery. LEVEL OF EVIDENCE: Level II, therapeutic study.

Patient-Reported Outcomes Measurement Information System Outcome Measures and Mental Health in Orthopaedic Trauma Patients During Early Recovery.

OBJECTIVES: This study explored the relationships between negative affective states (depression and anxiety), physical/functional status, and emotional well-being during early treatment and later in recovery after orthopaedic trauma injury. DESIGN: This was a secondary observational analysis from a randomized controlled study performed at a Level-1 trauma center. PATIENTS: Patients with orthopaedic trauma (N = 101; 43.5 ± 16.4 years, 40.6% women) were followed from acute care to week 12 postdischarge. MAIN OUTCOME MEASURES: Patient-reported outcomes measurement information system measures of Physical Function, Psychosocial Illness Impact-Positive and Satisfaction with Social Roles and Activities and the Beck Depression Inventory-II and the State-Trait Anxiety Inventory were administered during acute care and at weeks 2, 6, and 12. Secondary measures included hospital length of stay, adverse readmissions, injury severity, and surgery number. RESULTS: At week 12, 20.9% and 35.3% of patients reported moderate-to-severe depression (Beck Depression Inventory-II score ≥20 points) and anxiety (State-Anxiety score ≥40 points), respectively. Depressed patients had greater length of stay, complex injuries, and more readmissions than those without. The study sample improved patient-reported outcomes measurement information system T-scores for Physical Function and Satisfaction with Social Roles and Activities by 40% and 22.8%, respectively (P < 0.0001), by week 12. Anxiety attenuated improvements in physical function. Both anxiety and depression were associated with lower Psychosocial Illness Impact-Positive scores by week 12. CONCLUSIONS: Although significant improvements in patient-reported physical function and satisfaction scores occurred in all patients, patients with depression or anxiety likely require additional psychosocial support and resources during acute care to improve overall physical and emotional recovery after trauma. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adding electrical stimulation during standard rehabilitation after stroke to improve motor function. A systematic review and meta-analysis.

BACKGROUND: Clinical studies have shown that sensory input improves motor function when added to active training after neurological injuries in the spinal cord. OBJECTIVE: We aimed to determine the effect on motor function of extremities of adding an electrical sensory modality without motor recruitment before or with routine rehabilitation for hemiparesis after stroke by a comprehensive systematic review and meta-analysis. METHODS: We searched databases including MEDLINE via PubMed and the Cochrane Central Register of Controlled Trials from 1978 to the end of November 2017 for reports of randomized controlled trials or controlled studies of patients with a clinical diagnosis of stroke who underwent 1) transcutaneous electrical nerve stimulation (TENS) or peripheral electromyography-triggered sensory stimulation over a peripheral nerve and associated muscles or 2) acupuncture to areas that produced sensory effects, without motor recruitment, along with routine rehabilitation. Outcome measures were motor impairment, activity, and participation outcomes defined by the International Classification of Functioning, Disability and Health. RESULTS: The search yielded 11studies with data that could be included in a meta-analysis. Electrical sensory inputs, when paired with routine therapy, improved peak torque dorsiflexion (mean difference [MD] 2.44 Nm, 95% confidence interval [CI] 0.26-4.63). On subgroup analysis, the combined therapy yielded a significant difference in terms of sensory stimulation without motor recruitment only on the Timed Up and Go test in the chronic phase of stroke (MD 3.51sec, 95% CI 3.05-3.98). The spasticity score was reduced but not significantly (MD-0.83 points, 95% CI -1.77-0.10). CONCLUSION: Electrical sensory input can contribute to routine rehabilitation to improve early post-stroke lower-extremity impairment and late motor function, with no change in spasticity. Prolonged periods of sensory stimulation such as TENS combined with activity can have beneficial effects on impairment and function after stroke.

Pre-injury depression and anxiety in patients with orthopedic trauma and their treatment.

PURPOSE: Depressive symptoms have a known negative impact on outcomes following musculoskeletal injury. This study determined the pre-injury prevalence of psychiatric diagnoses of depression and anxiety, medication lapses and psychiatric consult services among patients admitted for orthopaedic trauma. METHODS: This is a retrospective study of data from our Level-1 trauma center. Patients admitted to the orthopaedic trauma service during 2010-2015 were included (N = 4053). Demographics, Injury Severity Scores (ISS), mental health diagnoses, psychotropic medications, medication type and delay, psychiatric consultation use, intensive care unit (ICU) stay and total hospital length of stay (LOS) were abstracted from medical records and the institutional trauma registry. RESULTS: The 12-month prevalence of a major depressive episode is 6.6%-8.6% in adults in the United States. In our database, only 152/4053 (3.8%) of the patients had documented medical history of depression (80%) or anxiety (30%), and these patients had a 32% longer LOS (p < 0.016). Nearly two-thirds of patients who used psychotropic medications prior to injury experienced a delay in receiving these medications in the hospital (median = 1.0 day, range 0-14 days). Sixteen percent of patients also received a new psychotropic medication while hospitalized: an antipsychotic (8/16 patients, to treat delirium), an anxiolytic (3/16 patients for acute anxiety), or an antidepressant (1/16). Among patients with depression or anxiety, 16.7% received a psychiatric consult. Patients with psychiatric consults had higher ISS, were more likely to have longer ICU LOS and had longer hospital LOS than those without consults (all p < 0.05). CONCLUSION: The prevalence of depression and anxiety is grossly under-reported in our registry compared to national prevalence data. Patients with pre-existing disease had longer LOS and a higher rate of extended ICU care. Further studies are needed to characterize the true prevalence of disease in this patient population and its effect on patient outcomes after traumatic orthopaedic injury.

Middle Cerebral Artery Occlusion Model of Stroke in Rodents: A Step-by-Step Approach.

Stroke is one of the leading causes of morbidity and mortality in developed countries and an immense amount of medical care resources are devoted to combat the poststroke debilitating consequences. The key to develop effective and clinically applicable treatment methodologies is a better understanding of the pathophysiology of the disease, including the root causes and targets for pharmacology. Developing these foundations requires the use of standard animal models that mimic the physicochemical process of the diseases that can reliably replicate results in order to test and fine-tune therapeutic modalities. Middle cerebral artery occlusion (MCAO), endothelin-1-induced ischemic stroke, photothrombosis, devascularization, embolization, and spontaneous infarction using hemorrhage are some examples of different animal models. Reliability of MCAO has been proved and due to the ability to induce reperfusion similar to tissue plasminogen activator (tPA) therapy, this model is widely used in preclinical studies. Here, we describe a detailed methodology on how to develop MCAO stroke in rodents using intra-arterial insertion of filament to occlude the middle cerebral artery. This approach allows for the study of a wide array of basic pathophysiology mechanisms, regenerative medicine and rehabilitation therapy.

Depletion of neural stem cells from the subventricular zone of adult mouse brain using cytosine b-Arabinofuranoside.

INTRODUCTION: Neural stem cells (NSCs) reside along the ventricular axis of the mammalian brain. They divide infrequently to maintain themselves and the down-stream progenitors. Due to the quiescent property of NSCs, attempts to deplete these cells using antimitotic agents such as cytosine b-Aarabinofuranoside (Ara-C) have not been successful. We hypothesized that implementing infusion gaps in Ara-C kill paradigms would recruit the quiescent NSCs and subsequently eliminate them from their niches in the subventricular zone (SVZ). METHODS: We infused the right lateral ventricle of adult mice brain with 2% Ara-C using four different paradigms--1: one week; 2: two weeks; 3, 4: two weeks with an infusion gap of 6 and 12 h on day 7. Neurosphere assay (NSA), neural colony-forming cell assay (N-CFCA) and immunofluorescent staining were used to assess depletion of NSCs from the SVZ. RESULTS: Neurosphere formation dramatically decreased in all paradigms immediately after Ara-C infusion. Reduction in neurosphere formation was more pronounced in the 3rd and 4th paradigms. Interestingly 1 week after Ara-C infusion, neurosphere formation recovered toward control values implying the presence of NSCs in the harvested SVZ tissue. Unexpectedly, N-CFCA in the 3rd paradigm, as one of the most effective paradigms, did not result in formation of NSC-derived colonies (colonies >2 mm) even from SVZs harvested 1 week after completion of Ara-C infusion. However, formation of big colonies with serial passaging capability, again confirmed the presence of NSCs. CONCLUSIONS: Overall, these data suggest Ara-C kill paradigms with infusion gaps deplete NSCs in the SVZ more efficiently but the niches would repopulate even after the most vigorous kill paradigm used in this study.

Delivery of In Vivo Acute Intermittent Hypoxia in Neonatal Rodents to Prime Subventricular Zone-derived Neural Progenitor Cell Cultures.

Extended culture of neural stem/progenitor cells facilitates in vitro analyses to understand their biology while enabling expansion of cell populations to adequate numbers prior to transplantation. Identifying approaches to refine this process, to augment the production of all CNS cell types (i.e., neurons), and to possibly contribute to therapeutic cell therapy protocols is a high research priority. This report describes an easily applied in vivo "pre-conditioning" stimulus which can be delivered to awake, non-anesthetized animals. Thus, it is a non-invasive and non-stressful procedure. Specifically described are the procedures for exposing mouse or rat pups (aged postnatal day 1-8) to a brief (40-80 min) period of intermittent hypoxia (AIH). The procedures included in this video protocol include calibration of the whole-body plethysmography chamber in which pups are placed during AIH and the technical details of AIH exposure. The efficacy of this approach to elicit tissue-level changes in the awake animal is demonstrated through the enhancement of subsequent in vitro expansion and neuronal differentiation in cells harvested from the subventricular zone (SVZ). These results support the notion that tissue level changes across multiple systems could be observed following AIH, and support the continued optimization and establishment of AIH as a priming or conditioning modality for therapeutic cell populations.

The effects of repetitive transcranial magnetic stimulation on proliferation and differentiation of neural stem cells.

Repetitive transcranial magnetic stimulation (rTMS) is a new method for treating many neurological conditions; however, the exact therapeutic mechanisms behind rTMS-induced plasticity are still unknown. Neural stem and progenitor cells (NS/PCs) are active players in brain regeneration and plasticity but their behavior in the context of rTMS therapy needs further elucidation. We aimed to evaluate the effects of rTMS on proliferation and differentiation of NS/PCs in the subventricular zone (SVZ) of adult mouse brain. Adult male mice (n=30) were divided into rTMS (1-Hz and 30-Hz) and sham groups and treated for 7 or 14 consecutive days. Harvested NS/PCs from the SVZ were cultured in the neurosphere assay for 8 days and the number and size of the resulting neurospheres as well as their in vitro differentiation capacity were evaluated. After one week of rTMS treatment at 1-Hz and 30-Hz compared with sham stimulation, the mean neurosphere forming frequency per brain was not different while this measure significantly increased after two weeks (P<0.05). The mean neurosphere diameter in 1-Hz treatment paradigm was significantly larger compared with sham stimulation at both 1 and 2 weeks. In contrast, 30-Hz treatment paradigm resulted in significantly larger neurospheres only after 2 weeks. Importantly, rTMS treatment at both frequencies increased neuronal differentiation of the harvested NS/PCs. Furthermore, one week in vitro rTMS treatment of NS/PCs with both 1-Hz and 30-Hz increased NS/PCs proliferation and neuronal differentiation. It is concluded that both 1-Hz and 30-Hz rTMS treatment increase NS/PCs proliferation and neuronal differentiation.

The effects of whole body vibration on mobility and balance in Parkinson disease: a systematic review.

Whole body vibration (WBV) is a contemporary treatment modality that holds promise as an exercise training method in health-compromised individuals. A growing number of studies on individuals with Parkinson Disease are examining whether WBV improves balance and functional mobility. However, interpreting WBV studies is challenging since there is variability in the manner in which WBV intervention is conducted. The primary goal of this systematic review was to investigate the effect of WBV on improving mobility and balance as measured by a battery of clinical tests, in patients with Parkinson disease. Studies based on WBV parameters were characterized and a systematic search of peer-reviewed literature in five major databases was conducted. Randomized-controlled trials investigating the effects of WBV in patients with a Parkinson diagnosis and no cognitive impairment were included. A total of six publications met the inclusion criteria. Overall, studies demonstrated mixed results in favor of WBV for improving balance or mobility. The majority of studies seem to suggest a favorable benefit following WBV for mobility and balance, but not when compared to other active intervention or placebo. There was variability in the manner in which WBV intervention was applied. Variations among the six studies included: duration of intervention and rest, follow-up period, type of control groups, frequency of vibration, number of treatment sessions and sex distribution of subjects. Future research is needed to investigate the effects of different types of equipment and treatment dosage in individuals with Parkinson disease.

The neuroblast assay: an assay for the generation and enrichment of neuronal progenitor cells from differentiating neural stem cell progeny using flow cytometry.

Neural stem cells (NSCs) can be isolated and expanded in large-scale, using the neurosphere assay and differentiated into the three major cell types of the central nervous system (CNS); namely, astrocytes, oligodendrocytes and neurons. These characteristics make neural stem and progenitor cells an invaluable renewable source of cells for in vitro studies such as drug screening, neurotoxicology and electrophysiology and also for cell replacement therapy in many neurological diseases. In practice, however, heterogeneity of NSC progeny, low production of neurons and oligodendrocytes, and predominance of astrocytes following differentiation limit their clinical applications. Here, we describe a novel methodology for the generation and subsequent purification of immature neurons from murine NSC progeny using fluorescence activated cell sorting (FACS) technology. Using this methodology, a highly enriched neuronal progenitor cell population can be achieved without any noticeable astrocyte and bona fide NSC contamination. The procedure includes differentiation of NSC progeny isolated and expanded from E14 mouse ganglionic eminences using the neurosphere assay, followed by isolation and enrichment of immature neuronal cells based on their physical (size and internal complexity) and fluorescent properties using flow cytometry technology. Overall, it takes 5-7 days to generate neurospheres and 6-8 days to differentiate NSC progeny and isolate highly purified immature neuronal cells.

Neural-colony forming cell assay: an assay to discriminate bona fide neural stem cells from neural progenitor cells.

The neurosphere assay (NSA) is one of the most frequently used methods to isolate, expand and also calculate the frequency of neural stem cells (NSCs). Furthermore, this serum-free culture system has also been employed to expand stem cells and determine their frequency from a variety of tumors and normal tissues. It has been shown recently that a one-to-one relationship does not exist between neurosphere formation and NSCs. This suggests that the NSA as currently applied, overestimates the frequency of NSCs in a mixed population of neural precursor cells isolated from both the embryonic and adult mammalian brain. This video practically demonstrates a novel collagen based semi- solid assay, the neural-colony forming cell assay (N-CFCA), which has the ability to discriminate stem from progenitor cells based on their long-term proliferative potential, and thus provides a method to enumerate NSC frequency. In the N-CFCA, colonies ≥2 mm in diameter are derived from cells that meet all the functional criteria of a NSC, while colonies < 2mm are derived from progenitors. The N-CFCA procedure can be used for cells prepared from different sources including primary and cultured adult or embryonic mouse CNS cells. Here we use cells prepared from passage one neurospheres generated from embryonic day 14 mice brain to perform N-CFCA. The cultures are replenished with proliferation medium every seven days for three weeks to allow the plated cells to exhibit their full proliferative potential and then the frequency of neural progenitor and bona fide neural stem cells is calculated respectively by counting the number of colonies that are < 2mm and the ones that are ≥2mm in reference to the number of cells that were initially plated.

Establishing embryonic mouse neural stem cell culture using the neurosphere assay.

In mammalians, stem cells acts as a source of undifferentiated cells to maintain cell genesis and renewal in different tissues and organs during the life span of the animal. They can potentially replace cells that are lost in the aging process or in the process of injury and disease. The existence of neural stem cells (NSCs) was first described by Reynolds and Weiss (1992) in the adult mammalian central nervous system (CNS) using a novel serum-free culture system, the neurosphere assay (NSA). Using this assay, it is also feasible to isolate and expand NSCs from different regions of the embryonic CNS. These in vitro expanded NSCs are multipotent and can give rise to the three major cell types of the CNS. While the NSA seems relatively simple to perform, attention to the procedures demonstrated here is required in order to achieve reliable and consistent results. This video practically demonstrates NSA to generate and expand NSCs from embryonic day 14-mouse brain tissue and provides technical details so one can achieve reproducible neurosphere cultures. The procedure includes harvesting E14 mouse embryos, brain microdissection to harvest the ganglionic eminences, dissociation of the harvested tissue in NSC medium to gain a single cell suspension, and finally plating cells in NSA culture. After 5-7 days in culture, the resulting primary neurospheres are passaged to further expand the number of the NSCs for future experiments.

Isolation and expansion of the adult mouse neural stem cells using the neurosphere assay.

Isolation and expansion of the putative neural stem cells (NSCs) from the adult murine brain was first described by Reynolds and Weiss in 1992 employing a chemically defined serum-free culture system known as the neurosphere assay (NSA). In this assay, the majority of differentiated cell types die within a few days of culture but a small population of growth factor responsive precursor cells undergo active proliferation in the presence of epidermal growth factor (EGF) and/ basic fibroblastic growth factor (bFGF). These cells form colonies of undifferentiated cells called neurospheres, which in turn can be subcultured to expand the pool of neural stem cells. Moreover, the cells can be induced to differentiate, generating the three major cell types of the CNS i.e. neurons, astrocytes, and oligodendrocytes. This assay provides an invaluable tool to supply a consistent, renewable source of undifferentiated CNS precursors, which could be used for in vitro studies and also for therapeutic purposes. This video demonstrates the NSA method to generate and expand NSCs from the adult mouse periventricular region, and provides technical insights to ensure one can achieve reproducible neurosphere cultures. The procedure includes harvesting the brain from the adult mouse, micro-dissection of the periventricular region, tissue preparation and culture in the NSA. The harvested tissue is first chemically digested using trypsin-EDTA and then mechanically dissociated in NSC medium to achieve a single cell suspension and finally plated in the NSA. After 7-10 days in culture, the resulting primary neurospheres are ready for subculture to reach the amount of cells required for future experiments.