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Tan AQ, Tuthill C, Corsten AN, Barth S, Trumbower RD. A single sequence of intermittent hypoxia does not alter stretch reflex excitability in able-bodied individuals. Exp Physiol 2024; 109:576-587. [PMID: 38356241 PMCID: PMC10988685 DOI: 10.1113/ep091531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 12/21/2023] [Indexed: 02/16/2024]
Abstract
Spasticity attributable to exaggerated stretch reflex pathways, particularly affecting the ankle plantar flexors, often impairs overground walking in persons with incomplete spinal cord injury. Compelling evidence from rodent models underscores how exposure to acute intermittent hypoxia (AIH) can provide a unique medium to induce spinal plasticity in key inhibitory pathways mediating stretch reflex excitability and potentially affect spasticity. In this study, we quantify the effects of a single exposure to AIH on the stretch reflex in able-bodied individuals. We hypothesized that a single sequence of AIH will increase the stretch reflex excitability of the soleus muscle during ramp-and-hold angular perturbations applied to the ankle joint while participants perform passive and volitionally matched contractions. Our results revealed that a single AIH exposure did not significantly change the stretch reflex excitability during both passive and active matching conditions. Furthermore, we found that able-bodied individuals increased their stretch reflex response from passive to active matching conditions after both sham and AIH exposures. Together, these findings suggest that a single AIH exposure might not engage inhibitory pathways sufficiently to alter stretch reflex responses in able-bodied persons. However, the generalizability of our present findings requires further examination during repetitive exposures to AIH along with potential reflex modulation during functional movements, such as overground walking.
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Affiliation(s)
- Andrew Q. Tan
- Department of Integrative PhysiologyUniversity of ColoradoBoulderColoradoUSA
| | - Christopher Tuthill
- Department of Physical Medicine and RehabilitationHarvard Medical SchoolBostonMassachusettsUSA
- Department of Physical Medicine and RehabilitationINSPIRE LaboratorySpaulding Rehabilitation HospitalBostonMassachusettsUSA
| | - Anthony N. Corsten
- Department of Physical Medicine and RehabilitationINSPIRE LaboratorySpaulding Rehabilitation HospitalBostonMassachusettsUSA
| | - Stella Barth
- Department of Physical Medicine and RehabilitationINSPIRE LaboratorySpaulding Rehabilitation HospitalBostonMassachusettsUSA
| | - Randy D. Trumbower
- Department of Physical Medicine and RehabilitationHarvard Medical SchoolBostonMassachusettsUSA
- Department of Physical Medicine and RehabilitationINSPIRE LaboratorySpaulding Rehabilitation HospitalBostonMassachusettsUSA
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2
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Wiles MD, Benson I, Edwards L, Miller R, Tait F, Wynn-Hebden A. Management of acute cervical spinal cord injury in the non-specialist intensive care unit: a narrative review of current evidence. Anaesthesia 2024; 79:193-202. [PMID: 38088443 DOI: 10.1111/anae.16198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 01/11/2024]
Abstract
Each year approximately one million people suffer spinal cord injury, which has significant physical, psychosocial and economic impacts on patients and their families. Spinal cord rehabilitation centres are a well-established part of the care pathway for patients with spinal cord injury and facilitate improvements in functional independence and reductions in healthcare costs. Within the UK, however, there are a limited number of spinal cord injury centres, which delays admission. Patients and their families often perceive that they are not receiving specialist care while being treated in non-specialist units. This review aimed to provide clinicians who work in non-specialist spinal injury centres with a summary of contemporary studies relevant to the critical care management of patients with cervical spinal cord injury. We undertook a targeted literature review including guidelines, systematic reviews, meta-analyses, clinical trials and randomised controlled trials published in English between 1 June 2017 and 1 June 2023. Studies involving key clinical management strategies published before this time, but which have not been updated or repeated, were also included. We then summarised the key management themes: acute critical care management approaches (including ventilation strategies, blood pressure management and tracheostomy insertion); respiratory weaning techniques; management of pain and autonomic dysreflexia; and rehabilitation.
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Affiliation(s)
- M D Wiles
- Academic Department of Anaesthesia and Peri-operative Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Centre for Applied Health and Social Care Research, Sheffield Hallam University, Sheffield, UK
| | - I Benson
- National Spinal Injuries Centre, Buckinghamshire Hospitals NHS Trust, Stoke Mandeville, UK
| | - L Edwards
- University of Nottingham, Nottingham, UK
| | - R Miller
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - F Tait
- Critical Care Department, Northampton General Hospital, Northampton, UK
| | - A Wynn-Hebden
- Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust, Leicester, UK
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3
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Benson CA, Olson KL, Patwa S, Kauer SD, King JF, Waxman SG, Tan AM. Conditional Astrocyte Rac1KO Attenuates Hyperreflexia after Spinal Cord Injury. J Neurosci 2024; 44:e1670222023. [PMID: 37963762 PMCID: PMC10851682 DOI: 10.1523/jneurosci.1670-22.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 11/16/2023] Open
Abstract
Spasticity is a hyperexcitability disorder that adversely impacts functional recovery and rehabilitative efforts after spinal cord injury (SCI). The loss of evoked rate-dependent depression (RDD) of the monosynaptic H-reflex is indicative of hyperreflexia, a physiological sign of spasticity. Given the intimate relationship between astrocytes and neurons, that is, the tripartite synapse, we hypothesized that astrocytes might have a significant role in post-injury hyperreflexia and plasticity of neighboring neuronal synaptic dendritic spines. Here, we investigated the effect of selective Rac1KO in astrocytes (i.e., adult male and female mice, transgenic cre-flox system) on SCI-induced spasticity. Three weeks after a mild contusion SCI, control Rac1wt animals displayed a loss of H-reflex RDD, that is, hyperreflexia. In contrast, transgenic animals with astrocytic Rac1KO demonstrated near-normal H-reflex RDD similar to pre-injury levels. Reduced hyperreflexia in astrocytic Rac1KO animals was accompanied by a loss of thin-shaped dendritic spine density on α-motor neurons in the ventral horn. In SCI-Rac1wt animals, as expected, we observed the development of dendritic spine dysgenesis on α-motor neurons associated with spasticity. As compared with WT animals, SCI animals with astrocytic Rac1KO expressed increased levels of the glial-specific glutamate transporter, glutamate transporter-1 in the ventral spinal cord, potentially enhancing glutamate clearance from the synaptic cleft and reducing hyperreflexia in astrocytic Rac1KO animals. Taken together, our findings show for the first time that Rac1 activity in astrocytes can contribute to hyperreflexia underlying spasticity following SCI. These results reveal an opportunity to target cell-specific molecular regulators of H-reflex excitability to manage spasticity after SCI.Significance Statement Spinal cord injury leads to stretch reflex hyperexcitability, which underlies the clinical symptom of spasticity. This study shows for the first time that astrocytic Rac1 contributes to the development of hyperreflexia after SCI. Specifically, astrocytic Rac1KO reduced SCI-related H-reflex hyperexcitability, decreased dendritic spine dysgenesis on α-motor neurons, and elevated the expression of the astrocytic glutamate transporter-1 (GLT-1). Overall, this study supports a distinct role for astrocytic Rac1 signaling within the spinal reflex circuit and the development of SCI-related spasticity.
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Affiliation(s)
- Curtis A Benson
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Kai-Lan Olson
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Siraj Patwa
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Sierra D Kauer
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Jared F King
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Stephen G Waxman
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
| | - Andrew M Tan
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut 06510,
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut 06516
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4
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Mahrous A, Birch D, Heckman CJ, Tysseling V. Muscle Spasms after Spinal Cord Injury Stem from Changes in Motoneuron Excitability and Synaptic Inhibition, Not Synaptic Excitation. J Neurosci 2024; 44:e1695232023. [PMID: 37949656 PMCID: PMC10851678 DOI: 10.1523/jneurosci.1695-23.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023] Open
Abstract
Muscle spasms are common in chronic spinal cord injury (SCI), posing challenges to rehabilitation and daily activities. Pharmacological management of spasms mostly targets suppression of excitatory inputs, an approach known to hinder motor recovery. To identify better targets, we investigated changes in inhibitory and excitatory synaptic inputs to motoneurons as well as motoneuron excitability in chronic SCI. We induced either a complete or incomplete SCI in adult mice of either sex and divided those with incomplete injury into low or high functional recovery groups. Their sacrocaudal spinal cords were then extracted and used to study plasticity below injury, with tissue from naive animals as a control. Electrical stimulation of the dorsal roots elicited spasm-like activity in preparations of chronic severe SCI but not in the control. To evaluate overall synaptic inhibition activated by sensory stimulation, we measured the rate-dependent depression of spinal root reflexes. We found inhibitory inputs to be impaired in chronic injury models. When synaptic inhibition was blocked pharmacologically, all preparations became clearly spastic, even the control. However, preparations with chronic injuries generated longer spasms than control. We then measured excitatory postsynaptic currents (EPSCs) in motoneurons during sensory-evoked spasms. The data showed no difference in the amplitude of EPSCs or their conductance among animal groups. Nonetheless, we found that motoneuron persistent inward currents activated by the EPSCs were increased in chronic SCI. These findings suggest that changes in motoneuron excitability and synaptic inhibition, rather than excitation, contribute to spasms and are better suited for more effective therapeutic interventions.Significance Statement Neural plasticity following spinal cord injury is crucial for recovery of motor function. Unfortunately, this process is blemished by maladaptive changes that can cause muscle spasms. Pharmacological alleviation of spasms without compromising the recovery of motor function has proven to be challenging. Here, we investigated changes in fundamental spinal mechanisms that can cause spasms post-injury. Our data suggest that the current management strategy for spasms is misdirected toward suppressing excitatory inputs, a mechanism that we found unaltered after injury, which can lead to further motor weakness. Instead, this study shows that more promising approaches might involve restoring synaptic inhibition or modulating motoneuron excitability.
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Affiliation(s)
| | - Derin Birch
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
| | - C J Heckman
- Departments of Neuroscience
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
| | - Vicki Tysseling
- Departments of Neuroscience
- Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611
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Benson CA, King JF, Kauer SD, Waxman SG, Tan AM. Increased astrocytic GLT-1 expression in tripartite synapses is associated with SCI-induced hyperreflexia. J Neurophysiol 2023; 130:1358-1366. [PMID: 37877184 DOI: 10.1152/jn.00234.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/06/2023] [Accepted: 10/22/2023] [Indexed: 10/26/2023] Open
Abstract
Spasticity is a chronic neurological complication associated with spinal cord injury (SCI), characterized by increased muscle tone and stiffness. A physiological sign of spasticity is hyperreflexia, evident by the loss of evoked rate-dependent depression (RDD) in the H-reflex. Although previous work has shown that SCI-induced astrogliosis contributes to hyperexcitability disorders, including neuropathic pain and spasticity, it is unclear how reactive astrocytes can modulate synaptic transmission within the injured spinal cord. To study astrocytes' role in post-SCI hyperreflexia, we examined glutamate transporter-1 (GLT-1) and postsynaptic density protein 95 (PSD-95) proteins in astrocytes and neurons, respectively, within the ventral horn (lamina IX) below the level of injury (spinal segment L4-5). The close juxtaposition of GLT-1 and PSD-95 markers is a molecular correlate of tripartite synapses and is thought to be a key element in the astrocyte-induced plasticity of neuronal synapses. Our study compared animals with and without SCI-induced hyperreflexia and spasticity and investigated potential synaptic abnormalities associated with astrocyte involvement. As expected, 4 wk after SCI, we observed a loss in evoked H-reflex RDD in hindlimb electromyogram recordings, i.e., hyperreflexia, in contrast to uninjured sham. Importantly, our main findings show a significant increase in the presence of GLT-1-PSD-95 tripartite synapses in the ventral spinal cord motor regions of animals exhibiting SCI-induced hyperreflexia. Taken together, our study suggests the involvement of astrocyte-neuron synaptic complexes in the plasticity-driven progression of chronic spasticity.NEW & NOTEWORTHY The role of astrocytes in H-reflex hyperexcitability following SCI remains understudied. Our findings establish a relationship between GLT-1 expression, its proximity to neuronal PSD-95 in the spinal cord ventral horn, and the loss of H-reflex RDD, i.e., hyperreflexia. Our findings provide a new perspective on synaptic alterations and the development of SCI-related spasticity.
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Affiliation(s)
- Curtis A Benson
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States
| | - Jared F King
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States
| | - Sierra D Kauer
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States
| | - Stephen G Waxman
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States
| | - Andrew M Tan
- Department of Neurology and Center for Neuroscience and Regeneration Research, Yale University School of Medicine, New Haven, Connecticut, United States
- Rehabilitation Research Center, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, United States
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Bluvshtein V, Catz A, Gelernter I, Kfir A, Front L, Michaeli D, Bizzarini E, Margalho P, Soeira TP, Kesiktas N, Aidinoff E. The net contribution of rehabilitation to improvement in performance in patients with spinal cord lesions in five countries. J Spinal Cord Med 2023:1-7. [PMID: 37861289 DOI: 10.1080/10790268.2023.2271200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
CONTEXT Change in ability realization reflects the main contribution of rehabilitation to improvement in the performance of daily activities in patients with spinal cord lesions (SCL). OBJECTIVE To assess the net effect of rehabilitation of patients with SCL and compare it between countries. METHODS We calculated the Spinal Cord Ability Realization Measurement Index (SCI-ARMI) and its change from admission to rehabilitation to discharge, for inpatients admitted to SCL units in five countries, between 2016 and 2019. We used chi-square tests, analysis of variance (ANOVA), McNemar's test, Pearson's correlations, and analysis of covariance (ANCOVA) to compare countries and patient groups and assess the relationships of various factors with SCI-ARMI gain during rehabilitation. RESULTS The study included 218 inpatients (67% males, age 52 ± 17). In Brazil, Israel, Italy, Portugal, and Turkiye, respectively, SCI-ARMI gain was 2 (SD = 15), 19 (SD = 17), 31 (SD = 23), 13 (SD = 15), and 16 (SD = 12). Yet, after controlling for admission SCI-ARMI and the time from SCL onset to the examination, the effect of the country on ability realization gain was found non-significant (P = 0.086). CONCLUSION The study confirmed that rehabilitation makes a net contribution to improvement in performance in patients with SCL, beyond the contribution of neurological recovery. After controlling for affecting factors, this contribution was quite similar in the participating units from different countries.
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Affiliation(s)
- Vadim Bluvshtein
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Amiram Catz
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ilana Gelernter
- School of Mathematical Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Adi Kfir
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | - Lilach Front
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | - Dianne Michaeli
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
| | | | | | | | - Nur Kesiktas
- Istanbul Physical Medicine and Rehabilitation Hospital, University of Health Sciences, Turkiye
| | - Elena Aidinoff
- Department of Spinal Rehabilitation, Loewenstein Rehabilitation Hospital, Raanana, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Esquenazi A, Jost WH, Turkel CC, Wein T, Dimitrova R. Treatment of adult spasticity with Botox (onabotulinumtoxinA): Development, insights, and impact. Medicine (Baltimore) 2023; 102:e32376. [PMID: 37499086 PMCID: PMC10374184 DOI: 10.1097/md.0000000000032376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Upper and lower limb spasticity (ULS, LLS) often occur following a stroke or in patients with other neurological disorders, leading to difficulties in mobility and daily living and decreased quality of life. Prior to the use of onabotulinumtoxinA, antispastic medications had limited efficacy and often caused sedation. Phenol injections were difficult for physicians to perform, painful, and led to tissue destruction. The success of onabotulinumtoxinA in treating cervical dystonia led to its use in spasticity. However, many challenges characterized the development of onabotulinumtoxinA for adult spasticity. The wide variability in the presentation of spasticity among patients rendered it difficult to determine which muscles to inject and how to measure improvement. Another challenge was the initial refusal of the Food and Drug Administration to accept the Ashworth Scale as a primary endpoint. Additional scales were designed to incorporate a goal-oriented, patient-centered approach that also accounted for the variability of spasticity presentations. Several randomized, double-blind, placebo-controlled trials of post-stroke spasticity of the elbow, wrist, and/or fingers showed significantly greater improvements in the modified Ashworth Scale and patient treatment goals and led to the approval of onabotulinumtoxinA for the treatment of ULS in adult patients. Lessons learned from the successful ULS trials were applied to design an LLS trial that led to approval for the latter indication. Additional observational trials mimicking real-world treatment have shown continued effectiveness and patient satisfaction. The use of onabotulinumtoxinA for spasticity has ushered in a more patient-centered treatment approach that has vastly improved patients' quality of life.
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Affiliation(s)
| | - Wolfgang H Jost
- Department of Neurology, University of Freiburg, Freiburg, Germany, and Parkinson-Hospital Ortenau, Wolfach, Germany
| | | | - Theodore Wein
- Department of Neurology, McGill University, Montreal, QC, Canada
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Gumussu K, Erhan B. Management of spasticity in individuals with spinal cord injury in the era of COVID-19 pandemic societal restrictions. Spinal Cord Ser Cases 2023; 9:17. [PMID: 37085485 PMCID: PMC10121424 DOI: 10.1038/s41394-023-00573-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 03/30/2023] [Accepted: 04/03/2023] [Indexed: 04/23/2023] Open
Abstract
STUDY DESIGN Cross-sectional telephone interviews. OBJECTIVE The coronavirus disease (COVID-19) pandemic placed unprecedented pressure on healthcare systems worldwide. Here, we aimed to investigate the disruptions in management of spasticity and activities of daily living (ADL) in individuals with spinal cord injury (SCI) during the COVID-19 pandemic. SETTING Two university hospitals in Istanbul, Turkey. METHODS Twenty-four individuals with SCI exhibiting moderate and severe spasticity were enroled. All participants underwent ultrasound-guided botulinum toxin type A (BoNT-A) injections at two centres. A self-rated spasticity survey prepared by the authors was conducted. We questioned whether there was an increase in spasticity and the need for new BoNT-A injections during the societal restrictions of the COVID-19 pandemic. Spasticity severity in the previous week was rated using a numeric rating scale (NRS). ADL disrupted by spasticity were assessed by asking open-ended questions. RESULTS In total, 75% participants reported a moderate increase in spasticity, 12.5% reported a severe increase, and 12.5% reported no difference. The mean spasticity NRS score was 6 (standard deviation = 2). Further, 87.5% (21) participants reported the need for BoNT-A treatment because of symptom re-emergence. When spasticity-induced deterioration in ADL was assessed, individuals mostly reported difficulties in walking, sitting on a wheelchair, and sleep disturbance due to spasticity. CONCLUSIONS Most (87.5%) individuals with SCI reported a moderate or severe increase in spasticity during COVID-19 restrictions. Individuals with disabilities are an especially sensitive group and require specialised care during extraordinary circumstances, such as pandemics, hurricanes, or earthquakes. SPONSORSHIP None.
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Affiliation(s)
- Kevser Gumussu
- University of Health Sciences, Gaziosmanpasa Training and Research Hospital, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey.
| | - Belgin Erhan
- Istanbul Medeniyet University, School of Medicine, Department of Physical Medicine and Rehabilitation, Istanbul, Turkey
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9
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Bandres MF, Gomes JL, McPherson JG. Motor-targeted spinal stimulation promotes concurrent rebalancing of pathologic nociceptive transmission in chronic spinal cord injury. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.04.12.536477. [PMID: 37090665 PMCID: PMC10120632 DOI: 10.1101/2023.04.12.536477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Electrical stimulation of spinal networks below a spinal cord injury (SCI) is a promising approach to restore functions compromised by inadequate excitatory neural drive. The most translationally successful examples are paradigms intended to increase neural transmission in weakened yet spared motor pathways and spinal motor networks rendered dormant after being severed from their inputs by lesion. Less well understood is whether spinal stimulation is also capable of reducing neural transmission in pathways made pathologically overactive by SCI. Debilitating spasms, spasticity, and neuropathic pain are all common manifestations of hyperexcitable spinal responses to sensory feedback. But whereas spasms and spasticity can often be managed pharmacologically, SCI-related neuropathic pain is notoriously medically refractory. Interestingly, however, spinal stimulation is a clinically available option for ameliorating neuropathic pain arising from etiologies other than SCI, and it has traditionally been assumed to modulate sensorimotor networks overlapping with those engaged by spinal stimulation for motor rehabilitation. Thus, we reasoned that spinal stimulation intended to increase transmission in motor pathways may simultaneously reduce transmission in spinal pain pathways. Using a well-validated pre-clinical model of SCI that results in severe bilateral motor impairments and SCI-related neuropathic pain, we show that the responsiveness of neurons integral to the development and persistence of the neuropathic pain state can be enduringly reduced by motor-targeted spinal stimulation while preserving spinal responses to non-pain-related sensory feedback. These results suggest that spinal stimulation paradigms could be intentionally designed to afford multi-modal therapeutic benefits, directly addressing the diverse, intersectional rehabilitation goals of people living with SCI.
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10
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Waller M, Jörgensen S, Lexell J. Changes over 6 years in secondary health conditions and activity limitations in older adults aging with long-term spinal cord injury. PM R 2023; 15:157-167. [PMID: 35092167 DOI: 10.1002/pmrj.12776] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 11/19/2021] [Accepted: 12/28/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND The number of individuals aging with long-term spinal cord injury (SCI) is increasing. Still, there is limited knowledge about changes in secondary health conditions (SHCs) and activity limitations over time. OBJECTIVES To determine changes in SHCs and activity limitations in older adults aging with long-term SCI over 6 years, and to investigate how changes in SHCs and activity limitations are associated with gender, age, and injury characteristics. DESIGN Longitudinal cohort study from the Swedish Aging with Spinal Cord Injury Study (SASCIS). SETTING Community settings, Sweden. PARTICIPANTS From the initial 123 participants in the SASCIS: 78 individuals (32% women); mean age 68 years; mean time since injury 31 years; injury levels C1-L3, AIS A-D. INTERVENTIONS Not applicable MAIN OUTCOME MEASURE: Bowel and bladder function and problems, pain, spasticity, and the Spinal Cord Independence Measure (SCIM III). RESULTS Over 6 years, bowel-related problems increased (31% to 47%, p = .015) and the occurrence of constipation doubled to 24% (p = .013). There were increases in frequent urinary tract infections (10% to 26%, p = .004), use of indwelling urinary catheters (15% to 23%, p = .031), and other bladder-related problems (4% to 22%, p < .001). The occurrence of pain was high (85%), with no significant change. Spasticity increased from 41% to 62% (p < .001). Activity limitations increased (SCIM III total score mean 67 to 61, p < .001, with significant decreases in all subscales). The increase in bowel-related problems was greater in males, and the deterioration in self-care was greater in participants with longer time since injury and with traumatic injuries. CONCLUSIONS These findings support the notion that SHCs and activity limitations increase over time in older adults aging with long-term SCI. The results can inform clinicians and call for a proactive, holistic approach in the long-term follow-up to support healthy and active aging.
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Affiliation(s)
- Mikael Waller
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Rehabilitation Medicine, Sunderby Hospital, Norrbotten County Council, Luleå, Sweden
| | - Sophie Jörgensen
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
| | - Jan Lexell
- Department of Health Sciences, Lund University, Lund, Sweden.,Department of Rehabilitation Medicine, Skåne University Hospital, Lund, Sweden
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11
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Sydney-Smith JD, Koltchev AM, Moon LDF, Warren PM. Delayed viral vector mediated delivery of neurotrophin-3 improves skilled hindlimb function and stability after thoracic contusion. Exp Neurol 2023; 360:114278. [PMID: 36455639 DOI: 10.1016/j.expneurol.2022.114278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/07/2022] [Accepted: 11/19/2022] [Indexed: 11/30/2022]
Abstract
Intramuscular injection of an Adeno-associated viral vector serotype 1 (AAV1) encoding Neurotrophin-3 (NT3) into hindlimb muscles 24 h after a severe T9 spinal level contusion in rats has been shown to induce lumbar spinal neuroplasticity, partially restore locomotive function and reduce spasms during swimming. Here we investigate whether a targeted delivery of NT3 to lumbar and thoracic motor neurons 48 h following a severe contusive injury aids locomotive recovery in rats. AAV1-NT3 was injected bilaterally into the tibialis anterior, gastrocnemius and rectus abdominus muscles 48-h following trauma, persistently elevating serum levels of the neurotrophin. NT3 modestly improved trunk stability, accuracy of stepping during skilled locomotion, and alternation of the hindlimbs during swimming, but it had no effect on gross locomotor function in the open field. The number of vGlut1+ boutons, likely arising from proprioceptive afferents, on gastrocnemius α-motor neurons was increased after injury but normalised following NT3 treatment, suggestive of a mechanism in which functional benefits may be mediated through proprioceptive feedback. Ex vivo MRI revealed substantial loss of grey and white matter at the lesion epicentre but no effect of delayed NT3 treatment to induce neuroprotection. Lower body spasms and hyperreflexia of an intrinsic paw muscle were not reliably induced in this severe injury model suggesting a more complex anatomical or physiological cause to their induction. We have shown that delayed intramuscular AAV-NT3 treatment can promote recovery in skilled stepping and coordinated swimming, supporting a role for NT3 as a therapeutic strategy for spinal injuries potentially through modulation of somatosensory feedback.
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Affiliation(s)
- Jared D Sydney-Smith
- The Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London Bridge, London SE1 1UL, UK
| | - Alice M Koltchev
- The Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London Bridge, London SE1 1UL, UK
| | - Lawrence D F Moon
- The Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London Bridge, London SE1 1UL, UK
| | - Philippa M Warren
- The Wolfson Centre for Age-Related Diseases, Guy's Campus, King's College London, London Bridge, London SE1 1UL, UK.
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12
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Cotinat M, Boquet I, Ursino M, Brocard C, Jouve E, Alberti C, Bensoussan L, Viton JM, Brocard F, Blin O. Riluzole for treating spasticity in patients with chronic traumatic spinal cord injury: Study protocol in the phase ib/iib adaptive multicenter randomized controlled RILUSCI trial. PLoS One 2023; 18:e0276892. [PMID: 36662869 PMCID: PMC9858801 DOI: 10.1371/journal.pone.0276892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/15/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Satisfactory treatment is often lacking for spasticity, a highly prevalent motor disorder in patients with spinal cord injury (SCI). Low concentrations of riluzole potently reduce the persistent sodium current, the post-SCI increase in which contributes to spasticity. The repurposing of this drug may therefore constitute a useful potential therapeutic option for relieving SCI patients suffering from chronic traumatic spasticity. OBJECTIVE RILUSCI is a phase 1b-2b trial designed to assess whether riluzole is a safe and biologically effective means of managing spasticity in adult patients with traumatic chronic SCI. METHODS In this multicenter double-blind trial, adults (aged 18-65 years) suffering from spasticity after SCI (target enrollment: 90 participants) will be randomly assigned to be given either a placebo or a recommended daily oral dose of riluzole for two weeks. The latter dose will be previously determined in phase 1b of the study by performing double-blind dose-finding tests using a Bayesian continuous reassessment method. The primary endpoint of the trial will be an improvement in the Modified Ashworth Score (MAS) or the Numerical Rating Score (NRS) quantifying spasticity. The secondary outcomes will be based on the safety and pharmacokinetics of riluzole as well as its impact on muscle spasms, pain, bladder dysfunction and quality of life. Analyses will be performed before, during and after the treatment and the placebo-controlled period. CONCLUSION To the best of our knowledge, this clinical trial will be the first to document the safety and efficacy of riluzole as a means of reducing spasticity in patients with chronic SCI. TRIAL REGISTRATION The clinical trial, which is already in progress, was registered on the ClinicalTrials.gov website on August 9, 2016 under the registration number NCT02859792. TRIAL SPONSOR Assistance Publique-Hôpitaux de Marseille.
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Affiliation(s)
- Maëva Cotinat
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Department of Physical and Rehabilitation Medicine, Sainte Marguerite University Hospital, APHM, Marseille, France
| | - Isabelle Boquet
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Moreno Ursino
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, FCRIN PARTNERS Platform, Université de Paris, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, USPC, Université de Paris, F-75006 Paris, France
- Inria, Paris, France
| | - Cécile Brocard
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Elisabeth Jouve
- Aix Marseille University, APHM, INSERM, Inst Neurosci Syst, UMR1106, Service de Pharmacologie Clinique et Pharmacovigilance, Marseille, France
| | - Corinne Alberti
- Unit of Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Centre Hospitalier Universitaire Robert Debré, FCRIN PARTNERS Platform, Université de Paris, Sorbonne Paris-Cité, INSERM U1123 and CIC-EC 1426, Paris, France
| | - Laurent Bensoussan
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Institut Universitaire de Réadaptation de Valmante Sud, UGECAM, Marseille, France
| | - Jean-Michel Viton
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
- Department of Physical and Rehabilitation Medicine, Sainte Marguerite University Hospital, APHM, Marseille, France
| | - Frédéric Brocard
- Institut de Neurosciences de la Timone (UMR7289), Aix-Marseille Université and CNRS, Marseille, France
| | - Olivier Blin
- Aix Marseille University, APHM, INSERM, Inst Neurosci Syst, UMR1106, Service de Pharmacologie Clinique et Pharmacovigilance, Marseille, France
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13
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Zhang C, Meng X, Chen L, Zhang X, Hans H, Ren L. Changes in 5-HT1F receptor expression in rats with spasticity following spinal cord injury. Neurosci Lett 2023; 793:136988. [PMID: 36471527 DOI: 10.1016/j.neulet.2022.136988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/08/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
Spasticity is a common complication in patients with spinal cord injury (SCI) and adversely affects patients' quality of life. Little is known about the distribution of the serotonin 1F receptor (5-HT1FR) in the spinal cord, especially in relation to the spasticity caused by SCI. Adult male Wistar rats were divided into a sham-operation group and spinalized group. SCI-induced spasticity was caused by spinal transection at the second sacral segment. The spinal cord below the transection was obtained at the end of the experiment. The expression and distribution of 5-HT1FR in the spinal cord were analyzed. The results showed that the expression of 5-HT1FR (mRNA and protein) exhibited the same downward trend after spinal transection and reached the lowest expression level at 2 and 5 days, respectively. The expression of 5-HT1FR (mRNA and protein) thereafter gradually approached the levels in the sham-operation group after 60 days. Immunostaining suggested that 5-HT1FR showed particularly strong expression in the ventral horn (VH) region. The time course of 5-HT1FR mRNA downregulation is positively correlated with the development of tail spasticity after sacral spinal cord transection. There may be a connection between 5-HT1FR and the occurrence of spasticity, but elucidation of the specific mechanism needs further experimental verification.
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Affiliation(s)
- Chao Zhang
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China
| | - Xin Meng
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China
| | - Long Chen
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China
| | - Xiang Zhang
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China; Department of Pathology, Hebei Medical University, Shijiazhuang 050017, Hebei, China
| | - Hulbtorn Hans
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China; Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen DK-2200, Denmark
| | - Liqun Ren
- Institute of Basic Medicine/Hebei Key Laboratory of Nerve Injury and Repair, Chengde Medical University, Chengde 067000, Hebei, China.
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Comino-Suárez N, Gómez-Soriano J, Ceruelo-Abajo S, Vargas-Baquero E, Esclarín A, Avendaño-Coy J. Extracorporeal shock wave for plantar flexor spasticity in spinal cord injury: A case report and review of literature. World J Clin Cases 2023; 11:127-134. [PMID: 36687177 PMCID: PMC9846994 DOI: 10.12998/wjcc.v11.i1.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 11/28/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Approximately 65%-78% of patients with a spinal cord injury (SCI) develop any symptom of spasticity. The aim of this study was to investigate the tolerability and short-term effects of radial extracorporeal shock wave therapy (rESWT) on plantar flexor spasticity in a patient with incomplete SCI.
CASE SUMMARY An 18-year-old man with an incomplete SCI completed five sessions of rESWT. The primary outcomes were the changes in ankle-passive range of motion (A-PROM) and passive resistive force to ankle dorsiflexion. The outcomes were assessed at baseline (T0), immediately after treatment (T1) and 1 wk after the end of treatment (T2). The A-PROM increased by 15 degrees at T1 and 25 degrees at T2 compared with T0. The passive resistive force to ankle dorsiflexion at low velocity decreased by 33% at T1 and 55% at T2 in the gastrocnemius muscle and by 41% at T1 and 39% at T2 in the soleus muscle compared with T0. At high velocity, it also decreased by 44% at T1 and 30% at T2 in the gastrocnemius muscle compared with T0. However, in the soleus muscle, the change was minor, with a decrease of 12% at T1 and increased by 39% at T2 compared with T0.
CONCLUSION In this patient, the findings showed that rESWT combined with conventional therapy was well-tolerated and could be effective in improving A-PROM and passive resistive force to ankle dorsiflexion in the short-term. Further randomized controlled clinical trials with longer period of follow-up are necessary to confirm the results obtained in patients with SCI.
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Affiliation(s)
- Natalia Comino-Suárez
- Toledo Physiotherapy Research Group, Faculty of Physiotherapy and Nursery, Castilla La Mancha University, Toledo 45071, Toledo, Spain
| | - Julio Gómez-Soriano
- Toledo Physiotherapy Research Group, Faculty of Physiotherapy and Nursery, Castilla La Mancha University, Toledo 45071, Toledo, Spain
| | - Silvia Ceruelo-Abajo
- Department of Physical and Rehabilitation Medicine, Hospital Nacional de Parapléjicos, Sescam, Toledo 45071, Toledo, Spain
| | - Eduardo Vargas-Baquero
- Department of Physical and Rehabilitation Medicine, Hospital Nacional de Parapléjicos, Sescam, Toledo 45071, Toledo, Spain
| | - Ana Esclarín
- Department of Physical and Rehabilitation Medicine, Hospital Nacional de Parapléjicos, Sescam, Toledo 45071, Toledo, Spain
| | - Juan Avendaño-Coy
- Toledo Physiotherapy Research Group, Faculty of Physiotherapy and Nursery, Castilla La Mancha University, Toledo 45071, Toledo, Spain
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Baricich A, Battaglia M, Cuneo D, Cosenza L, Millevolte M, Cosma M, Filippetti M, Dalise S, Azzollini V, Chisari C, Spina S, Cinone N, Scotti L, Invernizzi M, Paolucci S, Picelli A, Santamato A. Clinical efficacy of botulinum toxin type A in patients with traumatic brain injury, spinal cord injury, or multiple sclerosis: An observational longitudinal study. Front Neurol 2023; 14:1133390. [PMID: 37090974 PMCID: PMC10117778 DOI: 10.3389/fneur.2023.1133390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/09/2023] [Indexed: 04/25/2023] Open
Abstract
Botulinum toxin type A (BoNT-A) is the treatment of choice for focal spasticity, with a concomitant effect on pain reduction and improvement of quality of life (QoL). Current evidence of its efficacy is based mainly on post stroke spasticity. This study aims to clarify the role of BoNT-A in the context of non-stroke spasticity (NSS). We enrolled 86 patients affected by multiple sclerosis, spinal cord injury, and traumatic brain injury with clinical indication to perform BoNT-A treatment. Subjects were evaluated before injection and after 1, 3, and 6 months. At every visit, spasticity severity using the modified Ashworth scale, pain using the numeric rating scale, QoL using the Euro Qol Group EQ-5D-5L, and the perceived treatment effect using the Global Assessment of Efficacy scale were recorded. In our population BoNT-A demonstrated to have a significant effect in improving all the outcome variables, with different effect persistence over time in relation to the diagnosis and the number of treated sites. Our results support BoNT-A as a modifier of the disability condition and suggest its implementation in the treatment of NSS, delivering a possible starting point to generate diagnosis-specific follow-up programs. Clinical trial identifier NCT04673240.
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Affiliation(s)
- Alessio Baricich
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
- Physical and Rehabilitation Medicine, “Ospedale Maggiore della Carità” University Hospital, Novara, Italy
| | - Marco Battaglia
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
- Physical and Rehabilitation Medicine, “Ospedale Maggiore della Carità” University Hospital, Novara, Italy
- *Correspondence: Marco Battaglia
| | - Daria Cuneo
- Physical and Rehabilitation Medicine, A.S.L. Vercelli, Vercelli, Italy
| | - Lucia Cosenza
- Rehabilitation Unit, Department of Rehabilitation, “Santi Antonio e Biagio e Cesare Arrigo” National Hospital, Alessandria, Italy
| | - Marzia Millevolte
- Neurorehabilitation Clinic, Department Neurological Sciences, University Hospital of Ancona, Ancona, Italy
| | - Michela Cosma
- Neuroscience and Rehabilitation Department, Ferrara University Hospital, Ferrara, Italy
| | - Mirko Filippetti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Stefania Dalise
- Neurorehabilitation Section, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Valentina Azzollini
- Neurorehabilitation Section, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Carmelo Chisari
- Neurorehabilitation Section, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Stefania Spina
- Spasticity and Movement Disorder Unit, Physical Medicine and Rehabilitation, Policlinico Riuniti, University of Foggia, Foggia, Italy
| | - Nicoletta Cinone
- Spasticity and Movement Disorder Unit, Physical Medicine and Rehabilitation, Policlinico Riuniti, University of Foggia, Foggia, Italy
| | - Lorenza Scotti
- Department of Translational Medicine, Unit of Medical Statistics, Università del Piemonte Orientale, Novara, Italy
| | - Marco Invernizzi
- Physical and Rehabilitation Medicine, Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
- Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Translational Medicine, “Santi Antonio e Biagio e Cesare Arrigo” National Hospital, Alessandria, Italy
| | | | - Alessandro Picelli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Andrea Santamato
- Spasticity and Movement Disorder Unit, Physical Medicine and Rehabilitation, Policlinico Riuniti, University of Foggia, Foggia, Italy
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16
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Dietz N, Wagers S, Harkema SJ, D'Amico JM. Intrathecal and Oral Baclofen Use in Adults With Spinal Cord Injury: A Systematic Review of Efficacy in Spasticity Reduction, Functional Changes, Dosing, and Adverse Events. Arch Phys Med Rehabil 2023; 104:119-131. [PMID: 35750207 DOI: 10.1016/j.apmr.2022.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 04/29/2022] [Accepted: 05/06/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine the efficacy, dosing, and safety profiles of intrathecal and oral baclofen in treating spasticity after spinal cord injury (SCI). DATA SOURCES PubMed and Cochrane Databases were searched from 1970-2018 with keywords baclofen, spinal cord injury, and efficacy. STUDY SELECTION The database search yielded 588 sources and 10 additional relevant publications. After removal of duplicates, 398 publications were screened. DATA EXTRACTION Data were extracted using the following population, intervention, comparator, outcomes, and study designs criteria: studies including adult patients with SCI with spasticity; the intervention could be oral or intrathecal administration of baclofen; selection was inclusive for control groups, surgical management, rehabilitation, and alternative pharmaceutical agents; outcomes were efficacy, dosing, and adverse events. Randomized controlled trials, observational studies, and case reports were included. Meta-analyses and systematic reviews were excluded. DATA SYNTHESIS A total of 98 studies were included with 1943 patients. Only 4 randomized, double-blinded, and placebo-controlled trials were reported. Thirty-nine studies examined changes in the Modified Ashworth Scale (MAS; 34 studies) and Penn Spasm scores (Penn Spasm Frequency; 19 studies), with average reductions of 1.7±1.3 and 1.6±1.4 in individuals with SCI, respectively. Of these data, a total of 6 of the 34 studies (MAS) and 2 of the 19 studies (Penn Spasm Frequency) analyzed oral baclofen. Forty-three studies addressed adverse events with muscle weakness and fatigue frequently reported. CONCLUSIONS Baclofen is the most commonly-prescribed antispasmodic after SCI. Surprisingly, there remains a significant lack of large, placebo-controlled, double-blinded clinical trials, with most efficacy data arising from small studies examining treatment across different etiologies. In the studies reviewed, baclofen effectively improved spasticity outcome measures, with increased efficacy through intrathecal administration. Few studies assessed how reduced neural excitability affected residual motor function and activities of daily living. A host of adverse events were reported that may negatively affect quality of life. Comparative randomized controlled trials of baclofen and alternative treatments are warranted because these have demonstrated promise in relieving spasticity with reduced adverse events and without negatively affecting residual motor function.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Sarah Wagers
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Susan J Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY
| | - Jessica M D'Amico
- Department of Neurological Surgery, University of Louisville, Louisville, KY; Kentucky Spinal Cord Injury Research Center, Louisville, KY.
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Korupolu R, Malik A, Pemberton E, Stampas A, Li S. Phenol neurolysis in people with spinal cord injury: a descriptive study. Spinal Cord Ser Cases 2022; 8:90. [PMID: 36481543 PMCID: PMC9732339 DOI: 10.1038/s41394-022-00556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 10/12/2022] [Accepted: 11/29/2022] [Indexed: 12/13/2022] Open
Abstract
STUDY DESIGN Descriptive study. OBJECTIVES The study's main objective was to describe the common targets of phenol neurolysis and review the safety and efficacy of the dose used for this spasticity management procedure in people with spinal cord injury (SCI). SETTING An acute rehabilitation hospital. METHODS Data from people with SCI who underwent phenol neurolysis procedures for spasticity management between April 2017 and August 2018 were included in this study. We collected demographics and phenol neurolysis procedure-related information. RESULTS A total of 66 people with SCI and spasticity underwent phenol neurolysis of 303 nerves over 102 encounters. During these encounters, 97% of procedures were performed using both electrical stimulation and ultrasound guidance. The median (IQR) total volume of 6% aqueous phenol used per encounter was 4.0 (2.0-6.0) ml with a median (IQR) of 1.5 (1.0-2.3) ml per nerve. The most frequent target was the obturator nerve (33%), followed by the pectoral nerves (23%). Immediate post-phenol neurolysis improvement or reduction in spasticity was reported for 92% of all documented encounters. There was no documentation of any post-procedure-related adverse events in this cohort during this specified time frame. CONCLUSIONS Our findings suggest that phenol neurolysis can be safely used to manage spasticity in people with SCI under combined electrical stimulation and ultrasound guidance. Further research is required to assess the procedure's safety, efficacy, and cost-effectiveness on patient-reported outcomes compared to other spasticity interventions.
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Affiliation(s)
- Radha Korupolu
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
| | - Aila Malik
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA
| | - Erin Pemberton
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA
| | - Argyrios Stampas
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
| | - Sheng Li
- grid.267308.80000 0000 9206 2401Department of Physical Medicine and Rehabilitation, The University of Texas Health Sciences Center at Houston, Houston, TX USA ,grid.414053.70000 0004 0434 8100TIRR Memorial Hermann, Houston, TX USA
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Sangari S, Perez MA. Prevalence of spasticity in humans with spinal cord injury with different injury severity. J Neurophysiol 2022; 128:470-479. [PMID: 35507475 PMCID: PMC9423778 DOI: 10.1152/jn.00126.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/22/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
Spasticity is one of the most common symptoms manifested following spinal cord injury (SCI). The aim of this study was to assess spasticity in individuals with subacute and chronic SCI with different injury severity, standardizing the time and assessments of spasticity. We tested 110 individuals with SCI classified by the American Spinal Injury Association Impairment Scale (AIS) as either motor complete (AIS A and B; subacute, n = 25; chronic, n = 33) or motor incomplete (AIS C and D; subacute, n = 23; chronic, n = 29) at a similar time after injury (subacute, ∼1 mo after injury during inpatient rehabilitation and chronic, ≥1 yr after injury) using clinical (modified Ashworth scale) and kinematic (pendulum test) outcomes to assess spasticity in the quadriceps femoris muscle. Using both methodologies, we found that among individuals with subacute motor complete injuries, only a minority showed spasticity, whereas the majority exhibited no spasticity. This finding stands in contrast to individuals with subacute motor incomplete injury, where both methodologies revealed that a majority exhibited spasticity, whereas a minority exhibited no spasticity. In chronic injuries, most individuals showed spasticity regardless of injury severity. Notably, when spasticity was present, its magnitude was similar across injury severity in both subacute and chronic injuries. Our results suggest that the prevalence, not the magnitude, of spasticity differs between individuals with motor complete and incomplete SCI in the subacute and chronic stages of the injury. We thus argue that considering the "presence of spasticity" might help the stratification of participants with motor complete injuries for clinical trials.NEW & NOTEWORTHY The prevalence of spasticity in humans with SCI remains poorly understood. Using kinematic and clinical outcomes, we examined spasticity in individuals with subacute and chronic injuries of different severity. We found that spasticity in the quadriceps femoris muscle was more prevalent among individuals with subacute motor incomplete than in those with motor complete injuries. However, in a different group of individuals with chronic injuries, no differences were found in the prevalence of spasticity across injury severity.
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Affiliation(s)
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois
- Edward Hines Jr., VA Hospital, Hines, Illinois
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Samejima S, Henderson R, Pradarelli J, Mondello SE, Moritz CT. Activity-dependent plasticity and spinal cord stimulation for motor recovery following spinal cord injury. Exp Neurol 2022; 357:114178. [PMID: 35878817 DOI: 10.1016/j.expneurol.2022.114178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/22/2022] [Accepted: 07/16/2022] [Indexed: 02/07/2023]
Abstract
Spinal cord injuries lead to permanent physical impairment despite most often being anatomically incomplete disruptions of the spinal cord. Remaining connections between the brain and spinal cord create the potential for inducing neural plasticity to improve sensorimotor function, even many years after injury. This narrative review provides an overview of the current evidence for spontaneous motor recovery, activity-dependent plasticity, and interventions for restoring motor control to residual brain and spinal cord networks via spinal cord stimulation. In addition to open-loop spinal cord stimulation to promote long-term neuroplasticity, we also review a more targeted approach: closed-loop stimulation. Lastly, we review mechanisms of spinal cord neuromodulation to promote sensorimotor recovery, with the goal of advancing the field of rehabilitation for physical impairments following spinal cord injury.
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Affiliation(s)
- Soshi Samejima
- International Collaboration on Repair Discoveries, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Richard Henderson
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Jared Pradarelli
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Sarah E Mondello
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA
| | - Chet T Moritz
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, USA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA; Center for Neurotechnology, Seattle, WA, USA; Department of Physiology and Biophysics, University of Washington, Seattle, WA, USA.
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20
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Spasticity Management after Spinal Cord Injury: The Here and Now. J Pers Med 2022; 12:jpm12050808. [PMID: 35629229 PMCID: PMC9144471 DOI: 10.3390/jpm12050808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/04/2022] [Accepted: 05/07/2022] [Indexed: 02/06/2023] Open
Abstract
Spasticity is a common comorbidity of spinal cord injury (SCI) that is characterized by velocity dependent tone and spasms manifested by uninhibited reflex activity of muscles below the level of injury. For some, spasticity can be beneficial and facilitate functional standing, transfers, and some activities of daily living. For others, it may be problematic, painful, and interfere with mobility and function. This manuscript will address the anatomy and physiology of neuromuscular reflexes as well as the pathophysiology that occurs after SCI. Spasticity assessment will be discussed in terms of clinical history and findings on physical examinations, including responses to passive and active movement, deep tendon reflexes, and other long tract signs of upper motor neuron injury, as well as gait and function. Management strategies will be discussed including stretch, modalities, pharmacotherapy, neurolysis, and surgical options.
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21
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Liao YH, Chen MX, Chen SC, Luo KX, Wang B, Ao LJ, Liu Y. Low-Intensity Focused Ultrasound Alleviates Spasticity and Increases Expression of the Neuronal K-Cl Cotransporter in the L4–L5 Sections of Rats Following Spinal Cord Injury. Front Cell Neurosci 2022; 16:882127. [PMID: 35634464 PMCID: PMC9133482 DOI: 10.3389/fncel.2022.882127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Low-intensity focused ultrasound (LIFU) has been shown to provide effective activation of the spinal cord neurocircuits. The aim of this study was to investigate the effects of LIFU in order to alleviate spasticity following spinal cord injury (SCI) by activating the spinal neurocircuits and increasing the expression of the neuronal K-Cl cotransporter KCC2. Adult male Sprague Dawley (SD) rats (220–300 g) were randomly divided into a sham control group, a LIFU− group, and a LIFU+ group. The mechanical threshold hold (g) was used to evaluate the behavioral characteristics of spasm. Electromyography (EMG) was used to assess activation of the spinal cord neurocircuits and muscle spontaneous contraction. Spasticity was assessed by frequency-dependent depression (FDD). The expression of KCC2 of the lumbar spinal cord was determined via western blot (WB) and immunofluorescence (IF) staining. The spinal cord neurocircuits were activated by LIFU simulation, which significantly reduced the mechanical threshold (g), FDD, and EMG recordings (s) after 4 weeks of treatment. WB and IF staining both demonstrated that the expression of KCC2 was reduced in the LIFU− group (P < 0.05). After 4 weeks of LIFU stimulation, expression of KCC2 had significantly increased (P < 0.05) in the LIFU+ group compared with the LIFU− group. Thus, we hypothesized that LIFU treatment can alleviate spasticity effectively and upregulate the expression of KCC2 in the L4–L5 section of SCI rats.
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Affiliation(s)
- Ye-Hui Liao
- School of Rehabilitation, Kunming Medical University, Kunming, China
- Department of Orthopaedics, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Mo-Xian Chen
- School of Rehabilitation, Kunming Medical University, Kunming, China
| | - Shao-Chun Chen
- School of Rehabilitation, Kunming Medical University, Kunming, China
| | - Kai-Xuan Luo
- School of Rehabilitation, Kunming Medical University, Kunming, China
| | - Bing Wang
- School of Rehabilitation, Kunming Medical University, Kunming, China
| | - Li-Juan Ao
- School of Rehabilitation, Kunming Medical University, Kunming, China
- *Correspondence: Li-Juan Ao
| | - Yao Liu
- School of Rehabilitation, Kunming Medical University, Kunming, China
- Yao Liu
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22
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Dragojlovic N, Romanoski NL, Verduzco-Gutierrez M, Francisco GE. Prevalence and Treatment Characteristics of Spastic Hypertonia on First-Time Admission to Acute Inpatient Rehabilitation. Am J Phys Med Rehabil 2022; 101:348-352. [PMID: 34121067 DOI: 10.1097/phm.0000000000001823] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to report the prevalence of spasticity and treatment patterns during first-time admission to inpatient rehabilitation after acute stroke, traumatic brain injury, and spinal cord injury. DESIGN This is a retrospective cohort study. METHODS A review of 285 adult patients consecutively admitted to inpatient rehabilitation was conducted. Patients with a history of spasticity and inpatient rehabilitation course and those younger than 18 yrs were excluded. Main outcome measures are as follows: admitting diagnosis, length of stay, time from injury to admission, acute transfer rate, prevalence and severity of spasticity using Modified Ashworth Scale at admission and discharge, Functional Independence Measure scores at admission and discharge, Functional Independence Measure efficiency, and treatments for spasticity. RESULTS Stroke patients had the highest prevalence of spasticity: 68% on admission and 50% at discharge. In traumatic brain injury, spasticity prevalence was 55% on admission and 30% at discharge. In spinal cord injury, spasticity prevalence was 48% on admission and 46% at discharge. Patients with spinal cord injury received the most medications to control spasticity, whereas those with traumatic brain injury and stroke received the most procedural interventions. CONCLUSIONS Spasticity is a common sequela of upper motor neuron injury for patients admitted to inpatient rehabilitation. Early recognition and management are essential to prevent contractures, minimize pain, and maximize functional recovery.
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Affiliation(s)
- Nikola Dragojlovic
- From the Department of Physical Medicine and Rehabilitation, McGovern Medical School at UTHealth, Houston, Texas (ND, GEF); Department of Physical Medicine and Rehabilitation, Penn State Health, Hershey, Pennsylvania (NLR); and Department of Physical Medicine and Rehabilitation, UTHealth San Antonio, San Antonio, Texas (MV-G)
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23
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Hart SN, Patel SP, Michael FM, Stoilov P, Leow CJ, Hernandez AG, Jolly A, de la Grange P, Rabchevsky AG, Stamm S. Rat Spinal Cord Injury Associated with Spasticity Leads to Widespread Changes in the Regulation of Retained Introns. Neurotrauma Rep 2022; 3:105-121. [PMID: 35403103 PMCID: PMC8985541 DOI: 10.1089/neur.2021.0042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Samantha N. Hart
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, USA
| | - Samir P. Patel
- Department of Physiology and Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, Lexington, Kentucky, USA
| | - Felicia M. Michael
- Department of Physiology and Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, Lexington, Kentucky, USA
| | - Peter Stoilov
- Department of Biochemistry, University West Virginia, Morgantown, West Virginia, USA
| | - Chi Jing Leow
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, USA
| | | | | | | | - Alexander G. Rabchevsky
- Department of Physiology and Spinal Cord and Brain Injury Research Center (SCoBIRC), University of Kentucky, Lexington, Kentucky, USA
| | - Stefan Stamm
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, USA
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24
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Lee SW, Lim KB, Kim J, Lee H, Kim HS, Yoo J. Concordance between the international standards for neurological classification of spinal cord injury motor examination and needle electromyography findings in muscles with a motor power grade of zero or trace. J Spinal Cord Med 2022; 46:433-440. [PMID: 35007492 PMCID: PMC10114965 DOI: 10.1080/10790268.2021.2021044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
CONTEXT/OBJECTIVE To evaluate the accuracy of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor examination in individuals with spinal cord injury (SCI) with motor grade 0 or 1 and analyze its degree of concordance with needle electromyography (EMG) findings for each key muscle. DESIGN Retrospective study. SETTING University hospital in Goyang, Korea. PARTICIPANTS Individuals with SCI admitted to the Department of Rehabilitation from January 2013 to June 2019. INTERVENTIONS In the enrolled persons, needle EMG was performed on muscles with motor grade 0 or 1 on ISNCSCI examination, and muscle contraction was confirmed through the detection of motor unit action potential. OUTCOME MEASURES The agreement between motor examination and needle EMG findings was analyzed. RESULTS In 175 key muscles, needle EMG findings in 115 and 60 muscles evaluated as grades 0 and 1 on ISNCSCI examination showed 80% and 50% agreements, respectively. We found a fair agreement between motor examination and needle EMG findings (κ = 0.309, P < 0.0001). Moreover, statistically significant agreement was seen only in T1, L2, and S1 key muscles (κ = 1, P < 0.0001; κ = 0.359, P = 0.019; and κ = 0.521, P = 0.004, respectively). CONCLUSIONS It is important to accurately distinguish between grade 0 and 1 motor power to maximize the positive outcomes from rehabilitation treatment and predict the possibility of recovery in individuals with SCI. Therefore, to improve the accuracy of motor examination and the American Spinal Injury Association Impairment Scale, needle EMG confirmation could be considered for muscles with motor grade 0 or 1 in individuals with SCI.
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Affiliation(s)
- Sang Wan Lee
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Kil-Byung Lim
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Jiyong Kim
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Hojin Lee
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Ha Seong Kim
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
| | - Jeehyun Yoo
- Department of Physical Medicine and Rehabilitation, Ilsan Paik Hospital, Inje University, Goyang, Republic of Korea
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25
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Wecht JR, Savage WM, Famodimu GO, Mendez GA, Levine JM, Maher MT, Weir JP, Wecht JM, Carmel JB, Wu YK, Harel NY. Posteroanterior Cervical Transcutaneous Spinal Cord Stimulation: Interactions with Cortical and Peripheral Nerve Stimulation. J Clin Med 2021; 10:jcm10225304. [PMID: 34830584 PMCID: PMC8623612 DOI: 10.3390/jcm10225304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 11/06/2021] [Accepted: 11/09/2021] [Indexed: 12/27/2022] Open
Abstract
Transcutaneous spinal cord stimulation (TSCS) has demonstrated potential to beneficially modulate spinal cord motor and autonomic circuitry. We are interested in pairing cervical TSCS with other forms of nervous system stimulation to enhance synaptic plasticity in circuits serving hand function. We use a novel configuration for cervical TSCS in which the anode is placed anteriorly over ~C4–C5 and the cathode posteriorly over ~T2–T4. We measured the effects of single pulses of TSCS paired with single pulses of motor cortex or median nerve stimulation timed to arrive at the cervical spinal cord at varying intervals. In 13 participants with and 15 participants without chronic cervical spinal cord injury, we observed that subthreshold TSCS facilitates hand muscle responses to motor cortex stimulation, with a tendency toward greater facilitation when TSCS is timed to arrive at cervical synapses simultaneously or up to 10 milliseconds after cortical stimulus arrival. Single pulses of subthreshold TSCS had no effect on the amplitudes of median H-reflex responses or F-wave responses. These findings support a model in which TSCS paired with appropriately timed cortical stimulation has the potential to facilitate convergent transmission between descending motor circuits, segmental afferents, and spinal motor neurons serving the hand. Studies with larger numbers of participants and repetitively paired cortical and spinal stimulation are needed.
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Affiliation(s)
- Jaclyn R. Wecht
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - William M. Savage
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - Grace O. Famodimu
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - Gregory A. Mendez
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - Jonah M. Levine
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - Matthew T. Maher
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
| | - Joseph P. Weir
- Department of Health, Sport & Exercise Sciences, University of Kansas, Lawrence, KS 66045, USA;
| | - Jill M. Wecht
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jason B. Carmel
- Department of Orthopedic Surgery, Columbia University, New York, NY 10032, USA;
| | - Yu-Kuang Wu
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Noam Y. Harel
- James J. Peters VA Medical Center, Bronx, NY 10468, USA; (J.R.W.); (W.M.S.); (G.O.F.); (G.A.M.); (J.M.L.); (M.T.M.); (J.M.W.); (Y.-K.W.)
- Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Correspondence:
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26
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Zhang J, Mao G, Feng Y, Zhang B, Liu B, Lu X, Wang Z. Inhibiting Spasticity by Blocking Nerve Signal Conduction in Rats With Spinal Cord Transection. IEEE Trans Neural Syst Rehabil Eng 2021; 29:2355-2364. [PMID: 34723805 DOI: 10.1109/tnsre.2021.3124530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Spasticity is a common motor disorder following a variety of upper motor neuron lesions that seriously affects the quality of patient's life. We aimed to evaluate whether muscle spasms can be suppressed by blocking nerve signal conduction. A rat model of lower limb spasm was prepared and the conduction of pathological nerve signals were blocked to study the inhibitory effect of nerve signal block on muscle spasm. The experimental results showed that 4 weeks after the 9th segment of the rat's thoracic spinal cord was completely transacted, the H/M -ratio of the lower limbs increased, and rate-dependent depression was weakened. When the rat model was stimulated by external forces, the electromyography (EMG) signals of the spastic gastrocnemius muscles continued to erupt. After blocking the conduction of nerve signals in the rat sciatic nerve, the spastic EMG signal of the gastrocnemius muscle disappeared. The effective blocking time and blocking efficiency increased with increasing blocking signal amplitude, and the maximum blocking efficiency reached 73%. The experimental results of this study proved the feasibility of inhibiting lower limb spasticity by blocking nerve signal conduction.
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27
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Neto FR, Gomes Costa RR, Dorneles JR, Gonçalves CW, Veloso JHCL, Carregaro RL. Handgrip Strength Cutoff Points for Functional Independence and Wheelchair Ability in Men With Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2021; 27:60-69. [PMID: 34456547 DOI: 10.46292/sci20-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Objectives To determine optimal handgrip strength (HGS) cutoff points for greater functional independence and wheelchair skills in men with spinal cord injury (SCI), and to establish predictive equations for functional independence and wheelchair ability in men with SCI, based on demographic characteristics, HGS, and functionality. Methods In this cross-sectional study conducted at a rehabilitation hospital, 54 men with SCI were recruited and stratified into high and low paraplegia groups. All participants performed a maximum HGS test to determine cutoff points for the Spinal Cord Independence Measure (SCIM-III) and Adapted Manual Wheelchair Circuit (AMWC). The primary outcomes were the SCIM-III, AMWC, and HGS. Demographic characteristics obtained from participants' electronic medical records were the secondary outcomes, used as predictor variables of functional independence. Results The SCIM-III scale, performance score, and 3-minute overground wheeling test presented significant regression equations (R = 0.45, R = 0.69, and R = 0.72). The HGS showed a cutoff point of 102.5 kilogram force (kgf) to achieve a score of 70 on the SCIM-III and a 3-minute overground wheeling distance of 270 m. The HGS cutoff point to obtain a performance score of 23.7 seconds was 93.0 kgf. Conclusion The HGS was a significant predictor for the SCIM-III score, AMWC performance score, and 3-minute overground wheeling test. Three significant predictive equations were established based on HGS. The cutoff points could be adopted as parameters for optimal functional independence and wheelchair skills.
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Affiliation(s)
| | | | | | | | | | - Rodrigo L Carregaro
- College of Physical Education, Universidade de Brasilia (UnB), Brasilia, Brazil.,School of Physical Therapy, Universidade de Brasilia (UnB), Brasilia, Brazil
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28
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Preliminary Assessment of Muscle Activity and Muscle Characteristics during Training with Powered Robotic Exoskeleton: A Repeated-Measures Study. Healthcare (Basel) 2021; 9:healthcare9081003. [PMID: 34442139 PMCID: PMC8392199 DOI: 10.3390/healthcare9081003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/17/2022] Open
Abstract
A variety of robotic exoskeletons have been developed for patients with spinal cord injuries. However, the optimal training method and period for using a robotic exoskeleton have been uncertain until now. The purpose of this study is to determine the minimum training period for using a robotic exoskeleton with minimal muscle activity by investigating the changes in muscle activity and muscle characteristics of healthy adults during robotic exoskeleton training. A total of 16 people participated in the study. The robotic exoskeleton locomotion training consisted of three 50-min sessions a week for 7 weeks. The assessment consisted of sitting, standing, wide standing, sit-to-stand, and stand-to-sit where muscle activity and muscle characteristics were measured during each motion. All measurements were performed in the first session and every five sessions. Participants showed decreased muscle activity up to 10 sessions of training in the standing position, and 15 sessions in sit-to-stand and stand-to-sit motions. Upper extremity muscles showed decreased muscle activity, tone, stiffness, and logarithmic decrement up to the 15th session. The study results show that at least 15 training sessions are required to use the robotic exoskeleton with minimal load on the musculoskeletal system, and longer training is required for patients with spinal cord injury.
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29
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Zarkou A, Field-Fote EC. The influence of physiologic and atmospheric variables on spasticity after spinal cord injury. NeuroRehabilitation 2021; 48:353-363. [PMID: 33814472 DOI: 10.3233/nre-201625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND A number of physiological and atmospheric variables are believed to increase spasticity in persons with spinal cord injury (SCI) based on self-reported measures, however, there is limited objective evidence about the influence of these variables on spasticity. OBJECTIVE We investigated the relationship between physiological/ atmospheric variables and level of spasticity in individuals with SCI. METHODS In 53 participants with motor-incomplete SCI, we assessed the influence of age, time since injury, sex, injury severity, neurological level of injury, ability to walk, antispasmodic medication use, temperature, humidity, and barometric pressure on quadriceps spasticity. Spasticity was assessed using the pendulum test first swing excursion (FSE). To categorize participants based on spasticity severity, we performed cluster analysis. We used multivariate stepwise regression to determine variables associated with spasticity severity level. RESULTS Three spasticity groups were identified based on spasticity severity level: low, moderate, and high. The regression analysis revealed that only walking ability and temperature were significantly related to spasticity severity. CONCLUSIONS These outcomes validate the self-reported perception of people with SCI that low temperatures worsen spasticity. The findings refine prior evidence that people with motor-incomplete SCI have higher levels of spasticity, showing that those with sufficient motor function to walk have the highest levels of spasticity.
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Affiliation(s)
- Anastasia Zarkou
- Spinal Cord Injury Research Laboratory, Crawford Research Institute, Shepherd Center, Atlanta, GA, USA
| | - Edelle C Field-Fote
- Spinal Cord Injury Research Laboratory, Crawford Research Institute, Shepherd Center, Atlanta, GA, USA.,Division of Physical Therapy, School of Medicine, Emory University, Atlanta, GA, USA.,Program in Applied Physiology, School of Biological Sciences, Georgia Institute of Technology, Atlanta, GA, USA
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30
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Sangari S, Kirshblum S, Guest JD, Oudega M, Perez MA. Distinct patterns of spasticity and corticospinal connectivity following complete spinal cord injury. J Physiol 2021; 599:4441-4454. [PMID: 34107068 DOI: 10.1113/jp281862] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 06/01/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Damage to corticospinal axons have implications for the development of spasticity following spinal cord injury (SCI). Here, we examined to which extent residual corticospinal connections and spasticity are present in muscles below the injury (quadriceps femoris and soleus) in humans with motor complete thoracic SCI. We found three distinct sub-groups of people: participants with spasticity and corticospinal responses in the quadriceps femoris and soleus, participants with spasticity and corticospinal responses in the quadriceps femoris only, and participants with no spasticity or corticospinal responses in either muscle. Spasticity and corticospinal responses were present in the quadriceps but never only in the soleus muscle, suggesting a proximal to distal gradient of symptoms of hyperreflexia. These results suggest that concomitant patterns of residual corticospinal connectivity and spasticity exist in humans with motor complete SCI and that a clinical exam of spasticity might be a good predictor of residual corticospinal connectivity. ABSTRACT The loss of corticospinal axons has implications for the development of spasticity following spinal cord injury (SCI). However, the extent to which residual corticospinal connections and spasticity are present across muscles below the injury remains unknown. To address this question, we tested spasticity using the Modified Ashworth Scale and transmission in the corticospinal pathway by examining motor evoked potentials elicited by transcranial magnetic stimulation over the leg motor cortex (cortical MEPs) and by direct activation of corticospinal axons by electrical stimulation over the thoracic spine (thoracic MEPs), in the quadriceps femoris and soleus muscles, in 30 individuals with motor complete thoracic SCI. Cortical MEPs were also conditioned by thoracic electrical stimulation at intervals allowing their summation or collision. We found three distinct sub-groups of participants: 47% showed spasticity in the quadriceps femoris and soleus muscle, 30% showed spasticity in the quadriceps femoris muscle only, and 23% showed no spasticity in either muscle. While cortical MEPs were present only in the quadriceps in participants with spasticity, thoracic MEPs were present in both muscles when spasticity was present. Thoracic electrical stimulation facilitated and suppressed cortical MEPs, showing that both forms of stimulation activated similar corticospinal axons. Cortical and thoracic MEPs correlated with the degree of spasticity in both muscles. These results provide the first evidence that related patterns of residual corticospinal connectivity and spasticity exist in muscles below the injury after motor complete thoracic SCI and highlight that a clinical exam of spasticity can predict residual corticospinal connectivity after severe paralysis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Sina Sangari
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, 60611
| | - Steven Kirshblum
- Kessler Institute for Rehabilitation, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - James D Guest
- The Miami Project to Cure Paralysis, University of Miami, Miami, 33136
| | - Martin Oudega
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, 60611.,Edward Hines Jr. VA Hospital, Hines, Illinois, 60141
| | - Monica A Perez
- Shirley Ryan AbilityLab, Chicago, Illinois, 60611.,Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, 60611.,Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, 60611.,Edward Hines Jr. VA Hospital, Hines, Illinois, 60141
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31
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Kakodkar P, Fallah A, Tu A. Systematic review on use and efficacy of selective dorsal rhizotomy (SDR) for the management of spasticity in non-pediatric patients. Childs Nerv Syst 2021; 37:1837-1847. [PMID: 33928427 DOI: 10.1007/s00381-021-05167-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Selective dorsal rhizotomy (SDR) has been used to improve mobility and reduce lower extremity spasticity in patients with a various CNS conditions. Incidentally, literature on SDR has been performed in the pediatric population as such there is a paucity of research on the use in adult patients. METHODS Studies describing SDR in adults were identified from Medline and Embase databases. Combinations of search terms "Selective Dorsal Rhizotomy," "Selective Posterior Rhizotomy," and "Adult" were used. Only literature in English language on patients over the age of 18 years and that included measures for lower extremity outcome (i.e., spasticity, mobility) were included. Case reports, reviews without primary data, or inaccessible publications were excluded. RESULTS One hundred twenty-nine publications between 1970 and 2019 were identified. Twelve of these publications fit the inclusion criteria (n = 141 patients). In series where it was reported, SDR resulted in ambulatory improvement (54%, n = 44 out of 81), reduced spasticity (75.2%, n = 106 out of 141), and minimized muscle and joint pain (74.5%, n = 64 out of 86). SDR also showed improvement in parameters of the activities of daily life. 92.3% (n = 48 out of 52) of patients post-SDR developed new lower limb paresthesia. CONCLUSION The success and efficacy appear durable in the short-term, but further follow-up is necessary to validate these findings. The goal of the intervention dictates the ideal adult patient for SDR. Patients seeking ambulatory improvement, any etiology of spasticity besides MS, seem favorable. Positive locomotive predictors include the ability to isolate lower extremity function, lack of contractures, lower limb strength, and post-SDR physiotherapy.
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Affiliation(s)
- Pramath Kakodkar
- School of Medicine, National University of Ireland Galway, Galway, Republic of Ireland
| | - Aria Fallah
- Divison of Pediatric Neurosurgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Albert Tu
- Division of Pediatric Neurosurgery, Children's Hospital of Eastern Ontario, Rm 3359 CHEO, 401 Smyth Rd, Ottawa, ON, K1H 8L1, Canada.
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32
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Joseph D, Schulze J. Cannabinoid Activity-Is There a Causal Connection to Spasmolysis in Clinical Studies? Biomolecules 2021; 11:biom11060826. [PMID: 34205880 PMCID: PMC8229817 DOI: 10.3390/biom11060826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022] Open
Abstract
Cannabinoid drugs are registered for postoperative nausea and emesis, Tourette syndrome and tumor-related anorexia, but are also used for spasticity and pain relief, among other conditions. Clinical studies for spasmolysis have been equivocal and even conclusions from meta-analyses were not consistent. This may be due to uncertainty in diagnostic criteria as well as a lack of direct spasmolytic activity (direct causality). In this review we used the Hill criteria to investigate whether a temporal association is causal or spurious. Methods: A systematic literature search was performed to identify all clinical trials of cannabinoids for spasticity. Studies were evaluated for dose dependency and time association; all studies together were analyzed for reproducibility, coherence, analogy and mechanistic consistency. A Funnel plot was done for all studies to identify selection or publication bias. Results: Twenty-seven studies were included in this meta-analysis. The spasmolytic activity (effect strength) was weak, with a nonsignificant small effect in most studies and a large effect only in a few studies (“enriched” studies, low patient numbers). No dose dependency was seen and plotting effect size vs. daily dose resulted in a slope of 0.004. Most studies titrated the cannabinoid to the optimum dose, e.g., 20 mg/d THC. The effect decreased with longer treatment duration (3–4 months). The spasmolytic effect is consistent for different European countries but not always within a country, nor is the effect specific for an etiology (multiple sclerosis, spinal cord injury, others). For other criteria like plausibility, coherence or analogous effects, no data exist to support or refute them. In most studies, adverse effects were frequently reported indicating a therapeutic effect only at high doses with relevant side effects. Conclusions: Current data do not support a specific spasmolytic effect; a general decrease in CNS activity analogous to benzodiazepines appears more likely. Whether individual patients or specific subgroups benefit from cannabinoids is unclear. Further studies should compare cannabinoids with other, nonspecific spasmolytic drugs like benzodiazepines.
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Marcantoni M, Fuchs A, Löw P, Bartsch D, Kiehn O, Bellardita C. Early delivery and prolonged treatment with nimodipine prevents the development of spasticity after spinal cord injury in mice. Sci Transl Med 2021; 12:12/539/eaay0167. [PMID: 32295897 DOI: 10.1126/scitranslmed.aay0167] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 12/17/2019] [Accepted: 02/28/2020] [Indexed: 12/15/2022]
Abstract
Spasticity, one of the most frequent comorbidities of spinal cord injury (SCI), disrupts motor recovery and quality of life. Despite major progress in neurorehabilitative and pharmacological approaches, therapeutic strategies for treating spasticity are lacking. Here, we show in a mouse model of chronic SCI that treatment with nimodipine-an L-type calcium channel blocker already approved from the European Medicine Agency and from the U.S. Food and Drug Administration-starting in the acute phase of SCI completely prevents the development of spasticity measured as increased muscle tone and spontaneous spasms. The aberrant muscle activities associated with spasticity remain inhibited even after termination of the treatment. Constitutive and conditional silencing of the L-type calcium channel CaV1.3 in neuronal subtypes demonstrated that this channel mediated the preventive effect of nimodipine on spasticity after SCI. This study identifies a treatment protocol and suggests that targeting CaV1.3 could prevent spasticity after SCI.
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Affiliation(s)
- Maite Marcantoni
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen Denmark
| | - Andrea Fuchs
- Department of Neuroscience, Karolinska Institutet, 17162 Solna, Sweden
| | - Peter Löw
- Department of Neuroscience, Karolinska Institutet, 17162 Solna, Sweden
| | - Dusan Bartsch
- Transgenic Models, Central Institute of Mental Health, 28159 Mannheim, Germany
| | - Ole Kiehn
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen Denmark. .,Department of Neuroscience, Karolinska Institutet, 17162 Solna, Sweden
| | - Carmelo Bellardita
- Department of Neuroscience, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen Denmark
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Field-Fote EC, Furbish CL, Tripp NE, Zanca JM, Dyson-Hudson T, Kirshblum S, Heinemann AW, Chen D, Felix ER, Worobey L, Schmidt-Read M, Marino RJ, Hayat MJ. Characterizing the Experience of Spasticity after Spinal Cord Injury: A National Survey Project of the Spinal Cord Injury Model Systems Centers. Arch Phys Med Rehabil 2021; 103:764-772.e2. [PMID: 34015348 DOI: 10.1016/j.apmr.2021.03.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/14/2021] [Accepted: 03/23/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To characterize the qualities that individuals with spinal cord injury (SCI) associate with their experience of spasticity and to describe the relationship between spasticity and perceived quality of life and the perceived value of spasticity management approaches. DESIGN Online cross-sectional survey. SETTING Multicenter collaboration among 6 Spinal Cord Injury Model Systems hospitals in the United States. PARTICIPANTS Individuals with SCI (N=1076). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Qualities of Spasticity Questionnaire, modified Spinal Cord Injury-Spasticity Evaluation Tool (mSCI-SET), and the modified Patient-Reported Impact of Spasticity Measure (mPRISM). RESULTS Respondents indicated that spasms most often occurred in response to movement-related triggering events. However, spontaneous spasms (ie, no triggering event) were also reported to be among the most common types. Frequency of spasms appears to decline with age. The highest frequency of spasms was reported by 56% of respondents aged <25 years and by only 28% of those >55 years. Stiffness associated with spasticity was reported to be more common than spasms (legs, 65% vs 54%; trunk, 33% vs 18%; arms, 26% vs 15%). Respondents reported negative effects of spasticity more commonly than positive effects. Based on their association with negative scores on the mSCI-SET and the mPRISM, the 5 most problematic experiences reported were stiffness all day, interference with sleep, painful spasms, perceived link between spasticity and pain, and intensification of pain before a spasm. Respondents indicated spasticity was improved more by stretching (48%) and exercise (45%) than by antispasmodics (38%). CONCLUSIONS The experience of spasticity after SCI is complex and multidimensional, with consequences that affect mobility, sleep, comfort, and quality of life. Stiffness, rather than spasms, appears to be the most problematic characteristic of spasticity. Physical therapeutic interventions to treat spasticity warrant in-depth investigation.
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Affiliation(s)
- Edelle C Field-Fote
- Crawford Research Institute, Shepherd Center, Atlanta, GA; Division of Physical Therapy, Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA; Program in Applied Physiology, Georgia Institute of Technology, Atlanta, GA.
| | | | - Natalie E Tripp
- School of Public Health, Georgia State University, Atlanta, GA
| | | | | | - Steven Kirshblum
- Kessler Foundation, West Orange, NJ; Kessler Institute for Rehabilitation, West Orange, NJ; Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, NJ
| | - Allen W Heinemann
- Shirley Ryan AbilityLab, Chicago, IL; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | | | | | - Lynn Worobey
- Departments of Physical Medicine and Rehabilitation, Bioengineering and Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | | | - Ralph J Marino
- Department of Rehabilitation Medicine, Thomas Jefferson University, Philadephia, PA
| | - Matthew J Hayat
- School of Public Health, Georgia State University, Atlanta, GA
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Conditional RAC1 knockout in motor neurons restores H-reflex rate-dependent depression after spinal cord injury. Sci Rep 2021; 11:7838. [PMID: 33837249 PMCID: PMC8035187 DOI: 10.1038/s41598-021-87476-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/30/2021] [Indexed: 12/27/2022] Open
Abstract
A major complication with spinal cord injury (SCI) is the development of spasticity, a clinical symptom of hyperexcitability within the spinal H-reflex pathway. We have previously demonstrated a common structural motif of dendritic spine dysgenesis associated with hyperexcitability disorders after injury or disease insults to the CNS. Here, we used an adeno-associated viral (AAV)-mediated Cre-Lox system to knockout Rac1 protein expression in motor neurons after SCI. Three weeks after AAV9-Cre delivery into the soleus/gastrocnemius of Rac1-“floxed” adult mice to retrogradely infect spinal alpha-motor neurons, we observed significant restoration of RDD and reduced H-reflex excitability in SCI animals. Additionally, viral-mediated Rac1 knockdown reduced presence of dendritic spine dysgenesis on motor neurons. In control SCI animals without Rac1 knockout, we continued to observe abnormal dendritic spine morphology associated with hyperexcitability disorder, including an increase in mature, mushroom dendritic spines, and an increase in overall spine length and spine head size. Taken together, our results demonstrate that viral-mediated disruption of Rac1 expression in ventral horn motor neurons can mitigate dendritic spine morphological correlates of neuronal hyperexcitability, and reverse hyperreflexia associated with spasticity after SCI. Finally, our findings provide evidence of a putative mechanistic relationship between motor neuron dendritic spine dysgenesis and SCI-induced spasticity.
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Bilchak JN, Yeakle K, Caron G, Malloy D, Côté MP. Enhancing KCC2 activity decreases hyperreflexia and spasticity after chronic spinal cord injury. Exp Neurol 2021; 338:113605. [PMID: 33453210 PMCID: PMC7904648 DOI: 10.1016/j.expneurol.2021.113605] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/21/2020] [Accepted: 01/09/2021] [Indexed: 02/03/2023]
Abstract
After spinal cord injury (SCI), the majority of individuals develop spasticity, a debilitating condition involving involuntary movements, co-contraction of antagonistic muscles, and hyperreflexia. By acting on GABAergic and Ca2+-dependent signaling, current anti-spastic medications lead to serious side effects, including a drastic decrease in motoneuronal excitability which impairs motor function and rehabilitation efforts. Exercise, in contrast, decreases spastic symptoms without decreasing motoneuron excitability. These functional improvements coincide with an increase in expression of the chloride co-transporter KCC2 in lumbar motoneurons. Thus, we hypothesized that spastic symptoms can be alleviated directly through restoration of chloride homeostasis and endogenous inhibition by increasing KCC2 activity. Here, we used the recently developed KCC2 enhancer, CLP257, to evaluate the effects of acutely increasing KCC2 extrusion capability on spastic symptoms after chronic SCI. Sprague Dawley rats received a spinal cord transection at T12 and were either bike-trained or remained sedentary for 5 weeks. Increasing KCC2 activity in the lumbar enlargement improved the rate-dependent depression of the H-reflex and reduced both phasic and tonic EMG responses to muscle stretch in sedentary animals after chronic SCI. Furthermore, the improvements due to this pharmacological treatment mirror those of exercise. Together, our results suggest that pharmacologically increasing KCC2 activity is a promising approach to decrease spastic symptoms in individuals with SCI. By acting to directly restore endogenous inhibition, this strategy has potential to avoid severe side effects and improve the quality of life of affected individuals.
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Affiliation(s)
- Jadwiga N Bilchak
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Kyle Yeakle
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Guillaume Caron
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Dillon Malloy
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America
| | - Marie-Pascale Côté
- Marion Murray Spinal Cord Injury Research Center, Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA 19129, United States of America.
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Early escitalopram administration as a preemptive treatment strategy against spasticity after contusive spinal cord injury in rats. Sci Rep 2021; 11:7120. [PMID: 33782426 PMCID: PMC8007832 DOI: 10.1038/s41598-021-85961-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/23/2021] [Indexed: 11/29/2022] Open
Abstract
In the majority of spinal cord injury (SCI) patients, spasticity develops in the subacute phase and chronically persists with muscle hypertonia. Among various pathological conditions underlying spasticity, upregulated expression of 5-HT receptors (5-HTR) on the spinal motor neurons due to 5-HT denervation is considered one of crucial factors for hyperexcitability of the spinal circuit. As a 5-HT signal modulator, selective serotonin re-uptake inhibitors (SSRIs) are ordinarily prescribed for diseases associated with 5-HT in the CNS, and are known for their ability to increase 5-HT levels as well as to desensitize 5-HTR. Here, we hypothesized that early SSRI administration as a preemptive treatment strategy would effectively prevent the onset of spasticity. We used a rat model of contusive SCI and administered escitalopram during the first 4 weeks after injury, which is the period required for spasticity development in rodent models. We performed a swimming test to quantify spastic behaviors and conducted the Hoffman reflex test as well as histological analyses for 5-HT2AR and KCC2 expressions. Four weeks of escitalopram administration suppressed spastic behaviors during the swimming test and reduced the population of spasticity-strong rats. Moreover, the treatment resulted in decreased immunoreactivity of 5-HT2AR in the spinal motor neurons. Result of the H-reflex test and membrane expression of KCC2 were not significantly altered. In summary, early escitalopram administration could prevent the onset of spastic behaviors via regulation of 5-HT system after SCI, but could not modulate exaggerated spinal reflex. Our results suggest a novel application of SSRIs for preventative treatment of spasticity.
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Gong C, Zheng X, Guo F, Wang Y, Zhang S, Chen J, Sun X, Shah SZA, Zheng Y, Li X, Yin Y, Li Q, Huang X, Guo T, Han X, Zhang SC, Wang W, Chen H. Human spinal GABA neurons alleviate spasticity and improve locomotion in rats with spinal cord injury. Cell Rep 2021; 34:108889. [PMID: 33761348 DOI: 10.1016/j.celrep.2021.108889] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/21/2020] [Accepted: 03/01/2021] [Indexed: 01/10/2023] Open
Abstract
Spinal cord injury (SCI) often results in spasticity. There is currently no effective therapy for spasticity. Here, we describe a method to efficiently differentiate human pluripotent stem cells from spinal GABA neurons. After transplantation into the injured rat spinal cord, the DREADD (designer receptors exclusively activated by designer drug)-expressing spinal progenitors differentiate into GABA neurons, mitigating spasticity-like response of the rat hindlimbs and locomotion deficits in 3 months. Administering clozapine-N-oxide, which activates the grafted GABA neurons, further alleviates spasticity-like response, suggesting an integration of grafted GABA neurons into the local neural circuit. These results highlight the therapeutic potential of the spinal GABA neurons for SCI.
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Affiliation(s)
- ChenZi Gong
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaolong Zheng
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - FangLiang Guo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - YaNan Wang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Song Zhang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jing Chen
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - XueJiao Sun
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Sayed Zulfiqar Ali Shah
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - YiFeng Zheng
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiao Li
- School of Mechanical Engineering, Hubei University of Technology, Wuhan 430068, China
| | - Yatao Yin
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Qian Li
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - XiaoLin Huang
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Tiecheng Guo
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Xiaohua Han
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Su-Chun Zhang
- Waisman Center, Department of Neuroscience and Department of Neurology, University of Wisconsin, Madison, WI, USA; Program in Neuroscience & Behavioral Disorders, Duke-NUS Medical School, Singapore, Singapore
| | - Wei Wang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Hong Chen
- Department of Rehabilitation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Delhaas EM, Harhangi BS, van Doormaal PJ, Dinkelaar W, van Es AC, van Assema DM, Frankema SP, van der Lugt A, Huygen FJ. Restoration of rostral cerebrospinal fluid flow to solve treatment failure caused by obstruction in long-term intrathecal baclofen administration. J Spinal Cord Med 2021; 44:312-321. [PMID: 31418647 PMCID: PMC7952057 DOI: 10.1080/10790268.2019.1646476] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objects: We describe five traumatic spinal cord injury (SCI) patients with an intrathecal baclofen administration (ITB) failure caused by a rostral CSF flow obstruction referred to our expert center between January 2014 and January 2019. We discuss the diagnostic workup, rostral CSF flow obstruction as the cause of the ITB failure and treatment.Methods: When we could not determine the cause of the ITB failure through the patient's history, physical spasticity examination, pump readout, absence of fluid in the pump reservoir during aspiration, or plain radiography, we performed pump catheter access port (computed tomography [CT]) myelography. When CT myelography did not reveal the diagnosis, we used scintigraphy. In an obstruction, we aimed for CSF flow restoration. In three cases, we conducted a laminectomy with microsurgical adhesiolysis. In two of these patients, we could not achieve CSF flow restoration; thus, we placed an intradural catheter bypass. Recently, in three patients, we applied a less invasive technique of percutaneous fenestration of the obstruction.Results: In one case, we performed a successful catheter replacement. In another case using surgical adhesiolysis, spasticity control was complete. In two cases, we could obtain improvement with an additional intradural bypass, followed by a percutaneous fenestration of the obstruction, resulting in further improved CSF flow restoration. In one case, percutaneous fenestration was the first line of treatment. In all cases with percutaneous fenestration, we experienced spasticity control.Conclusion: Preliminary results showed that the restoration of rostral CSF flow might result in an effective ITB treatment in patients with an intrathecal obstruction.
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Affiliation(s)
- Elmar M. Delhaas
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands,Correspondence to: Elmar M. Delhaas, Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, P.O. Box 2040, Rotterdam, CA3000, The Netherlands.
| | - Biswadjiet S. Harhangi
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wouter Dinkelaar
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ad C.G.M. van Es
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Danielle M.E. van Assema
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sander P.G. Frankema
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Frank J.P.M. Huygen
- Center for Pain Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Michel-Flutot P, Mansart A, Deramaudt TB, Jesus I, Lee KZ, Bonay M, Vinit S. Permanent diaphragmatic deficits and spontaneous respiratory plasticity in a mouse model of incomplete cervical spinal cord injury. Respir Physiol Neurobiol 2021; 284:103568. [DOI: 10.1016/j.resp.2020.103568] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/21/2020] [Accepted: 10/25/2020] [Indexed: 12/21/2022]
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Nabata KJ, Tse EK, Nightingale TE, Lee AH, Eng JJ, Querée M, Walter M, Krassioukov AV. The Therapeutic Potential and Usage Patterns of Cannabinoids in People with Spinal Cord Injuries: A Systematic Review. Curr Neuropharmacol 2021; 19:402-432. [PMID: 32310048 PMCID: PMC8033968 DOI: 10.2174/1570159x18666200420085712] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/12/2020] [Accepted: 04/15/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND People with spinal cord injuries (SCI) commonly experience pain and spasticity; limitations of current treatments have generated interest in cannabis as a possible therapy. OBJECTIVES We conducted this systematic review to: 1) examine usage patterns and reasons for cannabinoid use, and 2) determine the treatment efficacy and safety of cannabinoid use in people with SCI. METHODS PubMed, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature databases were queried for keywords related to SCI and cannabinoids. RESULTS 7,232 studies were screened, and 34 were included in this systematic review. Though 26 studies addressed cannabinoid usage, only 8 investigated its therapeutic potential on outcomes such as pain and spasticity. The most common method of use was smoking. Relief of pain, spasticity and recreation were the most common reasons for use. A statistically significant reduction of pain and spasticity was observed with cannabinoid use in 83% and 100% of experimental studies, respectively. However, on examination of randomized control trials (RCTs) alone, effect sizes ranged from - 0.82 to 0.83 for pain and -0.95 to 0.09 for spasticity. Cannabinoid use was associated with fatigue and cognitive deficits. CONCLUSION Current evidence suggests that cannabinoids may reduce pain and spasticity in people with SCI, but its effect magnitude and clinical significance are unclear. Existing information is lacking on optimal dosage, method of use, composition and concentration of compounds. Long-term, double-blind, RCTs, assessing a wider range of outcomes should be conducted to further understand the effects of cannabinoid use in people with SCI.
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Affiliation(s)
| | | | | | | | | | | | | | - Andrei V. Krassioukov
- Address correspondence to this author at the International Collaboration On Repair Discoveries (ICORD), University of British Columbia (UBC), Vancouver, Canada; E-mail:
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Rodriguez G, Berri M, Lin P, Kamdar N, Mahmoudi E, Peterson MD. Musculoskeletal morbidity following spinal cord injury: A longitudinal cohort study of privately-insured beneficiaries. Bone 2021; 142:115700. [PMID: 33091639 PMCID: PMC9671069 DOI: 10.1016/j.bone.2020.115700] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/05/2020] [Accepted: 10/15/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND People living with spinal cord injuries (SCIs) experience motor, sensory and autonomic impairments that cause musculoskeletal disorders following the injury and that progress throughout lifetime. The range and severity of issues are largely dependent on level and completeness of the injury and preserved function. OBJECTIVE High risk of developing musculoskeletal morbidities among individuals after sustaining a traumatic SCI is well known in the clinical setting, however, there is a severe lack of evidence in literature. The objective of this study was to compare the incidence of and adjusted hazards for musculoskeletal morbidities among adults with and without SCIs. METHODS Privately-insured beneficiaries were included if they had an ICD-9-CM diagnostic code for SCI (n = 9081). Adults without SCI were also included (n = 1,474,232). Incidence estimates of common musculoskeletal morbidities (e.g., osteoporosis, sarcopenia, osteoarthritis, fractures, etc.) were compared at 5-years of enrollment. Survival models were used to quantify unadjusted and adjusted hazard ratios for incident musculoskeletal morbidities. RESULTS Adults living with traumatic SCIs had a higher incidence of any musculoskeletal morbidities (82.4% vs. 47.5%) as compared to adults without SCI, and differences were to a clinically meaningful extent. Survival models demonstrated that adults with SCI had a greater fully-adjusted hazard for any musculoskeletal morbidity (Hazard Ratio [HR]: 2.41; 95%CI: 2.30, 2.52), and all musculoskeletal disorders, and ranged from HR: 1.26 (1.14, 1.39) for rheumatoid arthritis to HR: 7.02 (6.58, 7.49) for pathologic fracture. CONCLUSIONS Adults with SCIs have a significantly higher incidence of and risk for common musculoskeletal morbidities, as compared to adults without SCIs. Efforts are needed to facilitate the development of improved clinical screening algorithms and early interventions to reduce risk of musculoskeletal disease onset/progression in this higher risk population.
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Affiliation(s)
- Gianna Rodriguez
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Maryam Berri
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Paul Lin
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Neil Kamdar
- Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, USA; Department of Emergency Medicine, Michigan Medicine, University of Michigan, USA; Department of Surgery, Michigan Medicine, University of Michigan, USA
| | - Elham Mahmoudi
- Department of Family Medicine, Michigan Medicine, University of Michigan, USA
| | - Mark D Peterson
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
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Ghatas MP, Khan MR, Gorgey AS. Skeletal muscle stiffness as measured by magnetic resonance elastography after chronic spinal cord injury: a cross-sectional pilot study. Neural Regen Res 2021; 16:2486-2493. [PMID: 33907038 PMCID: PMC8374562 DOI: 10.4103/1673-5374.313060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Skeletal muscle stiffness is altered after spinal cord injury (SCI). Assessing muscle stiffness is essential for rehabilitation and pharmaceutical interventions design after SCI. The study used magnetic resonance elastography to assess the changes in stiffness after chronic SCI compared to matched able-bodied controls and determine its association with muscle size, spasticity, and peak torque in persons with SCI. Previous studies examined the association between muscle stiffness and spasticity, however, we are unaware of other studies that examined the effects of muscle composition on stiffness after SCI. Ten participants (one female) with chronic SCI and eight (one female) matched able-bodied controls participated in this cross-sectional study. Magnetic resonance elastography was utilized to monitor stiffness derived from shear waves propagation. Modified Ashworth scale was used to evaluate spasticity scores in a blinded fashion. Peak isometric and isokinetic torques were measured using a biodex dynamometer. Stiffness values were non-significantly lower (12.5%; P = 0.3) in the SCI group compared to able-bodied controls. Moreover, stiffness was positively related to vastus lateralis whole muscle cross-sectional area (CSA) (r2 = 0.64, P < 0.005) and vastus lateralis absolute muscle CSA after accounting for intramuscular fat (r2 = 0.78, P < 0.0007). Stiffness was also positively correlated to both isometric (r2= 0.55-0.57, P < 0.05) and isokinetic peak (r2= 0.46-0.48, P < 0.05) torques. Our results suggest that larger clinical trial is warranted to confirm the preliminary findings that muscle stiffness is altered after SCI compared to healthy controls. Stiffness appeared to be influenced by infiltration of intramuscular fat and modestly by the spasticity of the paralyzed muscles. The preliminary data indicated that the relationship between muscle stiffness and peak torque is not altered with changing the frequency of pulses or angular velocities. All study procedures were approved by the Institutional Review Board at the Hunter Holmes McGuire VA Medical Center, USA (IRB #: 02314) on May 3, 2017.
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Affiliation(s)
- Mina P Ghatas
- Department of Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - M Rehan Khan
- Department of Radiology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA
| | - Ashraf S Gorgey
- Department of Spinal Cord Injury and Disorders, Hunter Holmes McGuire VA Medical Center; Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, USA
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Bezdudnaya T, Lane MA, Marchenko V. Pharmacological disinhibition enhances paced breathing following complete spinal cord injury in rats. Respir Physiol Neurobiol 2020; 282:103514. [PMID: 32750492 PMCID: PMC9793860 DOI: 10.1016/j.resp.2020.103514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/12/2020] [Accepted: 07/29/2020] [Indexed: 12/30/2022]
Abstract
Respiratory dysfunction is one of the most devastating and life-threatening deficits that occurs following cervical spinal cord injury (SCI). Assisted breathing with mechanical ventilators is a necessary part of care for many cervical injured individuals, but it is also associated with increased risk of secondary complications such as infection, muscle atrophy and maladaptive plasticity. Pre-clinical studies with epidural stimulation (EDS) have identified it as an alternative/additional method to support adequate lung ventilation without mechanical assistance. The full potential of EDS, however, may be limited by spinal inhibitory mechanisms within the injured spinal cord. The goal of the present work is to assess the potential improvement for EDS in combination with pharmacological disinhibition of spinal circuits following complete high cervical SCI. All experiments were performed in decerebrate, unanesthetized, non-paralyzed (n = 13) and paralyzed (n = 8) adult Sprague-Dawley rats 6 h following a complete C1 transection. The combination of high-frequency EDS (HF-EDS) at the C4 spinal segment with intrathecal delivery of GABA and glycine receptors antagonists (GABAzine and strychnine, respectively) resulted in significantly increased phrenic motor output, tidal volume and amplitude of diaphragm electrical activity compared to HF-EDS alone. Thus, it appears that spinal fast inhibitory mechanisms limit phrenic motor output and present a new neuropharmacological target to improve paced breathing in individuals with cervical SCI.
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Affiliation(s)
- T Bezdudnaya
- Drexel University College of Medicine, Department of Neurobiology & Anatomy, 2900 W Queen Lane, Philadelphia, PA, 19129, United States
| | - M A Lane
- Drexel University College of Medicine, Department of Neurobiology & Anatomy, 2900 W Queen Lane, Philadelphia, PA, 19129, United States
| | - V Marchenko
- Drexel University College of Medicine, Department of Neurobiology & Anatomy, 2900 W Queen Lane, Philadelphia, PA, 19129, United States; Medical College of Wisconsin, Department of Anesthesiology, 8701 W Watertown Plank Rd, Wauwatosa, WI, 53226, United States.
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Ertzgaard P, Nene A, Kiekens C, Burns AS. A review and evaluation of patient-reported outcome measures for spasticity in persons with spinal cord damage: Recommendations from the Ability Network - an international initiative. J Spinal Cord Med 2020; 43:813-823. [PMID: 30758270 PMCID: PMC7808317 DOI: 10.1080/10790268.2019.1575533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Context: Patient-reported outcome measures (PROMs) are valuable for capturing the impact of spasticity on health-related quality of life (HRQoL) in persons with spinal cord damage (SCD) and evaluating the efficacy of interventions. Objective: To provide practical guidance for measuring HRQoL in persons with spasticity following SCD. Methods: Literature reviews identified measures of HRQoL and caregiver burden, utilized in studies addressing spasticity in SCD. Identified measures were evaluated for clinical relevance and practicality for use in clinical practice and research. The PRISM, SCI-SET, EQ-5D and SF-36 instruments were mapped to the International Classification of Functioning, Disability and Health (ICF). The PRISM and SCI-SET were evaluated using the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) checklist. Results: Two spasticity-specific, five generic, and four preference-based measures were identified. ICF mapping and the COSMIN checklist supported the use of the PRISM and SCI-SET in SCD. The SF-36 is considered the most useful generic measure; disability-adapted versions may be more acceptable but further studies on psychometric properties are required. The SF-36 can be converted to a preference-based measure (SF-6D), or alternatively the EQ-5D can be used. While no measures specific to caregivers of people with SCD were identified, the Caregiver Burden Scale and the Zarit Burden Interview are considered suitable. Conclusion: Recommended measures include the PRISM and SCI-SET (condition-specific), SF-36 (generic), and Caregiver Burden Scale and Zarit Burden Interview (caregiver burden). Consideration should be given to using condition-specific and generic measures in combination; the PRISM or SCI-SET combined with SF-36 is recommended.
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Affiliation(s)
- Per Ertzgaard
- Rehabiliteringsmedicinska Kliniken, University Hospital, Linköping, Sweden,Correspondence to: Per Ertzgaard Rehabiliteringsmedicinska Kliniken, University Hospital, SE-582 85, Linköping, Sweden; phone +46 707955853. E-mail:
| | - Anand Nene
- Formerly, Roessingh Centre for Rehabilitation, Roessingh Research & Development, Enschede, The Netherlands
| | - Carlotte Kiekens
- Department of Development and Regeneration, KU Leuven – University of Leuven, Leuven, Belgium,Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Anthony S. Burns
- Division of Physiatry, Division of Medicine, University of Toronto, Toronto, Canada
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Saxena A, Sehgal S, Jangra MK. Effectiveness of Neurodynamic Mobilization versus Conventional Therapy on Spasticity Reduction and Upper Limb Function in Tetraplegic Patients. Asian Spine J 2020; 15:498-503. [PMID: 33059433 PMCID: PMC8377221 DOI: 10.31616/asj.2020.0146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN The study employed a pre- and post-test experimental design. PURPOSE This study was designed to assess the effect of neurodynamic mobilization of the median nerve on upper limb spasticity in tetraplegic patients. OVERVIEW OF LITERATURE Spasticity is a common and potentially disabling and bothersome complication in patients with spinal cord lesion; this disorder can negatively influence the quality of life by restricting the patient's ability to perform activities of daily living. Neural mobilization is currently used for reducing the spasticity in individuals with neurological disorders. METHODS Twenty subjects with traumatic spinal cord injury (level C5-C8) and upper limb spasticity in the finger and wrist flexors were enrolled. They were randomly allocated to two different groups using a computer-generated randomization schedule: group I comprised the neurodynamic mobilization group (n=11) and group II was the conventional therapy group (n=9); the subjects were administered therapy for 5 days every week for a period of 4 weeks. Upper limb spasticity was assessed using the Modified Ashworth Scale for wrist and finger flexors; F-wave amplitude, latency, and F-wave/M-wave amplitude ratio (F/M ratio) were examined using the F-wave scores of the median nerve; and upper limb function was determined using the Capabilities of Upper Extremity (CUE) Questionnaire. RESULTS After 4 weeks of intervention, between-group comparisons showed a significant difference in the pre-intervention and postintervention scores on the Modified Ashworth Scale score for wrist flexors (-1.64±0.67), Modified Ashworth Scale score for finger flexors (-1.00±0.63), F-wave amplitude (-154.09±220.86), F/M ratio (-0.18±0.24), and CUE scores (17.82±13.49). CONCLUSIONS These results suggest that neurodynamic mobilization of the median nerve may be effective for upper limb spasticity control and upper limb functional improvement in tetraplegic patients.
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Affiliation(s)
- Akanksha Saxena
- Department of Physiotherapy, Maharishi Markandeshwar University, Mullana, India
| | - Stuti Sehgal
- Division of Neurology, Department of Physiotherapy, Indian Spinal Injuries Center-Institute of Rehabilitation Sciences, New Delhi, India
| | - Mandeep Kumar Jangra
- Division of Cardiothoracic & Pulmonary Disorders, Department of Physiotherapy, Maharishi Markandeshwar University, Mullana, India
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Bergfeldt U, Strömberg J, Ramström T, Kulbacka-Ortiz K, Reinholdt C. Functional outcomes of spasticity-reducing surgery and rehabilitation at 1-year follow-up in 30 patients. J Hand Surg Eur Vol 2020; 45:807-812. [PMID: 32338191 DOI: 10.1177/1753193420918743] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The effects of spasticity-reducing surgery in the upper extremity were assessed in a prospective observational study of 30 consecutive patients with stroke (n = 13), incomplete spinal cord injury (n = 9), traumatic brain injury (n = 5), cerebral palsy (n = 2), and degenerative central nervous system disease (n = 1). Surgery, which included lengthening of tendons and release of muscles, was followed by early rehabilitation at three intensity levels depending on the patients' specific needs and conditions. At 12 months follow-up there were significant improvements in all outcome measures with the following mean values: spasticity decreased by 1.4 points (Modified Ashworth Scale, 0-5), visual analogue pain score by 1.3 points, and both Canadian Occupational Performance Measures increased (performance by 3.4 and satisfaction by 3.6), and most measures of joint position or mobility improved. Hand surgery combined with early and comprehensive rehabilitation improves function, activity and patients' satisfaction in patients with disabling spasticity with improvement lasting for at least 1 year.Level of evidence: II.
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Affiliation(s)
- Ulla Bergfeldt
- Centre for Advanced Reconstruction of Extremities, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Strömberg
- Centre for Advanced Reconstruction of Extremities, University of Gothenburg, Gothenburg, Sweden
| | - Therese Ramström
- Centre for Advanced Reconstruction of Extremities, University of Gothenburg, Gothenburg, Sweden
| | | | - Carina Reinholdt
- Centre for Advanced Reconstruction of Extremities, University of Gothenburg, Gothenburg, Sweden
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Distinct Corticospinal and Reticulospinal Contributions to Voluntary Control of Elbow Flexor and Extensor Muscles in Humans with Tetraplegia. J Neurosci 2020; 40:8831-8841. [PMID: 32883710 DOI: 10.1523/jneurosci.1107-20.2020] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/20/2020] [Accepted: 08/27/2020] [Indexed: 12/14/2022] Open
Abstract
Humans with cervical spinal cord injury (SCI) often recover voluntary control of elbow flexors and, to a much lesser extent, elbow extensor muscles. The neural mechanisms underlying this asymmetrical recovery remain unknown. Anatomical and physiological evidence in animals and humans indicates that corticospinal and reticulospinal pathways differentially control elbow flexor and extensor motoneurons; therefore, it is possible that reorganization in these pathways contributes to the asymmetrical recovery of elbow muscles after SCI. To test this hypothesis, we examined motor-evoked potentials (MEPs) elicited by transcranial magnetic stimulation over the arm representation of the primary motor cortex, maximal voluntary contractions, the StartReact response (a shortening in reaction time evoked by a startling stimulus), and the effect of an acoustic startle cue on MEPs elicited by cervicomedullary stimulation (CMEPs) on biceps and triceps brachii in males and females with and without chronic cervical incomplete SCI. We found that SCI participants showed similar MEPs and maximal voluntary contractions in biceps but smaller responses in triceps compared with controls, suggesting reduced corticospinal inputs to elbow extensors. The StartReact and CMEP facilitation was larger in biceps but similar to controls in triceps, suggesting enhanced reticulospinal inputs to elbow flexors. These findings support the hypothesis that the recovery of biceps after cervical SCI results, at least in part, from increased reticulospinal inputs and that the lack of these extra inputs combined with the loss of corticospinal drive contribute to the pronounced weakness found in triceps.SIGNIFICANCE STATEMENT Although a number of individuals with cervical incomplete spinal cord injury show limited functional recovery of elbow extensors compared with elbow flexor muscles, to date, the neural mechanisms underlying this asymmetrical recovery remain unknown. Here, we provide for the first time evidence for increased reticulospinal inputs to biceps but not triceps brachii and loss of corticospinal drive to triceps brachii in humans with tetraplegia. We propose that this reorganization in descending control contributes to the asymmetrical recovery between elbow flexor and extensor muscles after cervical spinal cord injury.
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Modified PRISM and SCI-SET Spasticity Measures for Persons With Traumatic Spinal Cord Injury: Results of a Rasch Analyses. Arch Phys Med Rehabil 2020; 101:1570-1579. [DOI: 10.1016/j.apmr.2020.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 02/28/2020] [Accepted: 05/09/2020] [Indexed: 11/23/2022]
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Caron G, Bilchak JN, Côté MP. Direct evidence for decreased presynaptic inhibition evoked by PBSt group I muscle afferents after chronic SCI and recovery with step-training in rats. J Physiol 2020; 598:4621-4642. [PMID: 32721039 DOI: 10.1113/jp280070] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 07/27/2020] [Indexed: 01/11/2023] Open
Abstract
KEY POINTS Presynaptic inhibition is modulated by supraspinal centres and primary afferents in order to filter sensory information, adjust spinal reflex excitability, and ensure smooth movement. After spinal cord injury (SCI), the supraspinal control of primary afferent depolarization (PAD) interneurons is disengaged, suggesting an increased role for sensory afferents. While increased H-reflex excitability in spastic individuals indicates a possible decrease in presynaptic inhibition, it remains unclear whether a decrease in sensory-evoked PAD contributes to this effect. We investigated whether the PAD evoked by hindlimb afferents contributes to the change in presynaptic inhibition of the H-reflex in a decerebrated rat preparation. We found that chronic SCI decreases presynaptic inhibition of the plantar H-reflex through a reduction in PAD evoked by posterior biceps-semitendinosus (PBSt) muscle group I afferents. We further found that step-training restored presynaptic inhibition of the plantar H-reflex evoked by PBSt, suggesting the presence of activity-dependent plasticity of PAD pathways activated by flexor muscle group I afferents. ABSTRACT Spinal cord injury (SCI) results in the disruption of supraspinal control of spinal networks and an increase in the relative influence of afferent feedback to sublesional neural networks, both of which contribute to enhancing spinal reflex excitability. Hyperreflexia occurs in ∼75% of individuals with a chronic SCI and critically hinders functional recovery and quality of life. It is suggested that it results from an increase in motoneuronal excitability and a decrease in presynaptic and postsynaptic inhibitory mechanisms. In contrast, locomotor training decreases hyperreflexia by restoring presynaptic inhibition. Primary afferent depolarization (PAD) is a powerful presynaptic inhibitory mechanism that selectively gates primary afferent transmission to spinal neurons to adjust reflex excitability and ensure smooth movement. However, the effect of chronic SCI and step-training on the reorganization of presynaptic inhibition evoked by hindlimb afferents, and the contribution of PAD has never been demonstrated. The objective of this study is to directly measure changes in presynaptic inhibition through dorsal root potentials (DRPs) and its association with plantar H-reflex inhibition. We provide direct evidence that H-reflex hyperexcitability is associated with a decrease in transmission of PAD pathways activated by posterior biceps-semitendinosus (PBSt) afferents after chronic SCI. More precisely, we illustrate that the pattern of inhibition evoked by PBSt group I muscle afferents onto both L4-DRPs and plantar H-reflexes evoked by the distal tibial nerve is impaired after chronic SCI. These changes are not observed in step-trained animals, suggesting a role for activity-dependent plasticity to regulate PAD pathways activated by flexor muscle group I afferents.
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Affiliation(s)
- Guillaume Caron
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University, Philadelphia, PA, 19129
| | - Jadwiga N Bilchak
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University, Philadelphia, PA, 19129
| | - Marie-Pascale Côté
- Marion Murray Spinal Cord Research Center, Department of Neurobiology and Anatomy, Drexel University, Philadelphia, PA, 19129
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