Motor Activated Auricular Vagus Nerve Stimulation as a Potential Neuromodulation Approach for Post-Stroke Motor Rehabilitation: A Pilot Study

BACKGROUND

Implanted vagus nerve stimulation (VNS), when synchronized with post-stroke motor rehabilitation improves conventional motor rehabilitation training. A non-invasive VNS method known as transcutaneous auricular vagus nerves stimulation (taVNS) has emerged, which may mimic the effects of implanted VNS.

OBJECTIVE

To determine whether taVNS paired with motor rehabilitation improves post-stroke motor function, and whether synchronization with movement and amount of stimulation is critical to outcomes.

METHODS

We developed a closed-loop taVNS system for motor rehabilitation called motor activated auricular vagus nerve stimulation (MAAVNS) and conducted a randomized, double-blind, pilot trial investigating the use of MAAVNS to improve upper limb function in 20 stroke survivors. Participants attended 12 rehabilitation sessions over 4-weeks, and were assigned to a group that received either MAAVNS or active unpaired taVNS concurrently with task-specific training. Motor assessments were conducted at baseline, and weekly during rehabilitation training. Stimulation pulses were counted for both groups.

RESULTS

A total of 16 individuals completed the trial, and both MAAVNS (n = 9) and unpaired taVNS (n = 7) demonstrated improved Fugl-Meyer Assessment upper extremity scores (Mean ± SEM, MAAVNS: 5.00 ± 1.02, unpaired taVNS: 3.14 ± 0.63). MAAVNS demonstrated greater effect size (Cohen's d = 0.63) compared to unpaired taVNS (Cohen's d = 0.30). Furthermore, MAAVNS participants received significantly fewer stimulation pulses (Mean ± SEM, MAAVNS: 36 070 ± 3205) than the fixed 45 000 pulses unpaired taVNS participants received (P < .05).

CONCLUSION

This trial suggests stimulation timing likely matters, and that pairing taVNS with movements may be superior to an unpaired approach. Additionally, MAAVNS effect size is comparable to that of the implanted VNS approach.

A feasibility study of objective outcome measures used in clinical trials of freezing of gait

BACKGROUND

Freezing of gait (FOG) is notoriously difficult to quantify, which has led to the use of multiple markers as outcomes for clinical trials. The instrumented timed up and go (TUG) and the many parameters that can be derived from it are commonly used as objective markers of FOG severity in clinical trials; however, it is unknown if they represent actual FOG severity.

OBJECTIVE

To determine the specificity and responsiveness of objective surrogate markers of FOG severity commonly utilized in FOG studies.

METHODS

Study design: We compared the specificity and responsiveness of commonly used markers in FOG clinical trials. Markers compared included velocity, step/stride length, step/stride length variability, TUG, and turn duration. Data was collected in four conditions (ON and OFF dopaminergic drugs, with and without a dual task). Unified Parkinson's Disease Rating Scale (UPDRS) was administered in the ON and OFF states.

RESULTS

Thirty-three subjects were recruited (17 PD subjects without FOG (PD-control) and 16 subjects with PD and dopa-responsive FOG PD-FOG). The UPDRS motor scores were 24.9 for the PD-control group in the ON state, 24.8 for the FOG group in the ON state, and 42.4 for the FOG group in the OFF state. Significant mean differences between the ON and OFF conditions were observed with all surrogate markers (p < 0.01). However, only dual task turn duration and step variability showed trends toward significance when comparing PD-control and ON-FOG (p = 0.08). Test-retest reliability was high (ICC > 0.90) for all markers except standard deviations. Step length variability was the only marker to show an area under the ROC curve analysis > 0.70 comparing ON-FOG vs. PD-control.

CONCLUSIONS

Multiple candidate surrogate markers for FOG severity showed responsiveness to levodopa challenge; however, most were not specific for FOG severity.

From adults to pediatrics: A review noninvasive brain stimulation (NIBS) to facilitate recovery from brain injury

Stroke is a major problem worldwide that impacts over 100 million adults and children annually. Rehabilitation therapy is the current standard of care to restore functional impairments post-stroke, however its effects are limited and many patients suffer persisting functional impairments and life-long disability. Noninvasive Brain Stimulation (NIBS) has emerged as a potential rehabilitation treatment option in both adults and children with brain injury. In the last decade, Transcranial Magnetic Stimulation (TMS), Transcranial Direct Current Stimulation (tDCS) and Transcutaneous Auricular Vagus Nerve Stimulation (taVNS) have been investigated to improve motor recovery in adults post-stroke. These promising adult findings using NIBS, however, have yet to be widely translated to the area of pediatrics. The limited studies exploring NIBS in children have demonstrated safety, feasibility, and utility of stimulation-augmented rehabilitation. This chapter will describe the mechanism of NIBS therapy (cortical excitability, neuroplasticity) that underlies its use in stroke and motor function and how TMS, tDCS, and taVNS are applied in adult stroke treatment paradigms. We will then discuss the current state of NIBS in early pediatric brain injury and will provide insight regarding practical considerations and future applications of NIBS in pediatrics to make this promising treatment option a viable therapy in children.

Pilot study of atomoxetine in patients with Parkinson's disease and dopa-unresponsive Freezing of Gait

Background

Freezing of gait (FoG) is a common and debilitating condition in Parkinson’s disease (PD) associated with executive dysfunction. A subtype of FoG does not respond to dopaminergic therapy and may be related to noradrenergic deficiency. This pilot study explores the effects of atomoxetine on gait in PD patients with dopa-unresponsive FoG using a novel paradigm for objective gait assessment.

Findings

Ten patients with PD and dopa-unresponsive FoG were enrolled in this eight-week open label pilot study. Assessments included an exploratory gait analysis protocol that quantified spatiotemporal parameters during straight-away walking and turning, while performing a dual task. Clinical, and subjective assessments of gait, quality of life, and safety were also administered. The primary outcome was a validated subjective assessment for FoG (FOG-Q). Atomoxetine was well tolerated, however, no significant change was observed in the primary outcome. The gait analysis protocol correlated well with clinical scales, but not with subjective assessments. DBS patients were more likely to increase gait velocity (p = 0.033), and improved in other clinical assessments.

Conclusions

Objective gait analysis protocols assessing gait while dual tasking are feasible and useful for this patient population, and may be superior correlates of FoG severity than subjective measures. These findings can inform future trials in this population.

Abstract 7: Dose Response Relationship in Transcranial Direct Current Stimulation Stroke Motor Recovery Studies

Background: Dozens of clinical trials investigated the potential efficacy of transcranial direct current stimulation (tDCS) in post-stroke motor recovery. Various current levels, pad size, number of sessions were used in different studies with mixed results in motor outcomes. We aimed to investigate a dose/current-response relationship by pooling published studies.

Methods: We identified relevant studies in Pubmed, EMBASE and clinicaltrials.gov from January 1990 to June 2014. We included sham-controlled randomized or quasi-randomized studies with ≥5 tDCS sessions and derived percent improvement in primary endpoint (percent improvement in treatment group - percent improvement in sham group) from each study. We plotted current, current density, charge per session, charge density per session, total charge and charge density with percent improvement. To assess the dose-response relationship, we conducted regression analyses where studies were weighed by the number of participants (sample size).

Results: We identified 8 studies with 272 subjects in total comparing active stimulation (anodal, cathodal or bi-hemispheric) with sham stimulation in terms of motor improvement. Pooling the results from these studies shows a positive dose/current-response relationship. Pearson’s correlation coefficients between percent improvement and current, current density, charge per session, charge density per session, total charge and charge density are –0.12, 0.2, 0.15, 0.27, 0.34 and 0.21, respectively.

Conclusion: By pooling studies, a dose response relationship is revealed and is best demonstrated by charge density per session. Phase II trials may be considered to formally assess this relationship in stroke patients towards determination of optimal dose in large clinical trials.

Early insulin therapy prevents beta cell loss in a mouse model for permanent neonatal diabetes (Munich Ins2(C95S))

AIMS

Heterozygous male Munich Ins2(C95S) mutant mice, a model for permanent neonatal diabetes mellitus, demonstrate a progressive diabetic phenotype with severe loss of functional beta cell mass. The aim of this study was to investigate the influence of early insulin treatment on glucose homeostasis and beta cell destruction in male Munich Ins2(C95S) mutants.

METHODS

One group of male Ins2(C95S) mutants was treated with subcutaneous insulin pellets, as soon as blood glucose levels began to rise; placebo-treated mutants and wild-type mice served as controls. An additional group of mutant mice received a sodium-dependent glucose transporter 2 (SGLT2) inhibitor (AVE2268) via rodent chow.

RESULTS

Insulin treatment normalised blood glucose concentrations, improved oral glucose tolerance, preserved insulin sensitivity and inhibited oxidative stress of Munich Ins2(C95S) mutant mice. Pancreatic C-peptide content, as well as total beta cell and isolated beta cell volumes, of insulin-treated mutant mice were higher than those of placebo-treated mutants. In addition, alpha cell dysfunction and hyperplasia of non-beta cells were completely normalised in insulin-treated mutant mice. Treatment with the SGLT2 inhibitor lowered blood glucose, improved glucose tolerance and normalised insulin sensitivity as well as oxidative stress of Ins2(C95S) mutants. The abundance of the endoplasmic reticulum (ER) stress markers binding Ig protein (BiP) and phosphorylated eukaryotic translation initiation factor 2 alpha (P-eIF2α) was significantly increased in the islets of mutants, before onset of hyperglycaemia, vs wild-type mice.

CONCLUSIONS

We conclude that early insulin treatment protects Munich Ins2(C95S) mutant mice from insulin resistance, alpha cell hyperfunction, beta cell loss and hyperplasia of non-beta cells, some well-known features of human diabetes mellitus. Therefore, insulin treatment may be considered early for human patients harbouring INS mutations.

Phenotypic and pathomorphological characteristics of a novel mutant mouse model for maturity-onset diabetes of the young type 2 (MODY 2)

Several mutant mouse models for human diseases such as diabetes mellitus have been generated in the large-scale Munich ENU (N-ethyl-N-nitrosourea) mouse mutagenesis project. The aim of this study was to identify the causal mutation of one of these strains and to characterize the resulting diabetic phenotype. Mutants exhibit a T to G transversion mutation at nt 629 in the glucokinase (Gck) gene, leading to an amino acid exchange from methionine to arginine at position 210. Adult Munich Gck(M210R) mutant mice demonstrated a significant reduction of hepatic glucokinase enzyme activity but equal glucokinase mRNA and protein abundances. While homozygous mutant mice exhibited growth retardation and died soon after birth in consequence of severe hyperglycemia, heterozygous mutant mice displayed only slightly elevated blood glucose levels, present from birth, with development of disturbed glucose tolerance and glucose-induced insulin secretion. Additionally, insulin sensitivity and fasting serum insulin levels were slightly reduced in male mutant mice from an age of 90 days onward. While beta-cell mass was unaltered in neonate heterozygous and homozygous mutant mice, the total islet and beta-cell volumes and the total volume of isolated beta-cells were significantly decreased in 210-day-old male, but not female heterozygous mutant mice despite undetectable apoptosis. These findings indicate that reduced total islet and beta-cell volumes of male mutants might emerge from disturbed postnatal islet neogenesis. Considering the lack of knowledge about the pathomorphology of maturity-onset diabetes of the young type 2 (MODY 2), this glucokinase mutant model of reduced total islet and total beta-cell volume provides the opportunity to elucidate the impact of a defective glucokinase on development and maintenance of beta-cell mass and its relevance in MODY 2 patients.

Effects of Trunk Restraint Combined With Intensive Task Practice on Poststroke Upper Extremity Reach and Function: A Pilot Study

Background. Poststroke reaching is characterized by excessive trunk motion and abnormal shoulder—elbow coordination. Little attention is typically given to arm—trunk kinematics during task practice. Preventing compensatory trunk motion during short-term practice immediately improves kinematics, but effects of longer-term practice are unknown. Objective. This study compared the effects of intensive task practice with and without trunk restraint on poststroke reaching kinematics and function. Methods. A total of 11 individuals with chronic stroke, baseline Fugl-Meyer Upper Extremity Assessment scores 26 to 54, were randomized to 2 constraint-therapy intervention groups. All participants wore a mitt on the unaffected hand for 90% of waking hours over 14 days and participated in 10 days/6 hours/day of supervised progressive task practice. During supervised sessions, one group trained with a trunk restraint (preventing anterior trunk motion) and one group did not. Tasks for the trunk-restraint group were located to afford repeated use of a shoulder flexion—elbow extension reaching pattern. Outcome measures included kinematics of unrestrained targeted reaching and tests of functional arm ability. Results. Posttraining, the trunk-restraint group demonstrated straighter reach trajectories ( P = .000) and less trunk displacement ( P = .001). The trunk-restraint group gained shoulder flexion ( P = .006) and elbow extension ( P = .022) voluntary ranges of motion, the nonrestraint group did not. Posttraining angle—angle plots illustrated that individuals from the trunk-restraint group transitioned from elbow flexion to elbow extension during mid-reach; individuals in the nonrestraint group retained pretraining movement strategies. Both groups gained functional arm ability ( P < .05 all tests). Conclusion. Intensive task practice structured to prevent compensatory trunk movements and promote shoulder flexion—elbow extension coordination may reinforce development of “normal” reaching kinematics.

Rare or remarkable microfungi from Oaxaca (south Mexico)--Part II

Microfungi were collected in southern Mexico in the vicinity of Puerto Escondido, Oaxaca in 2007. In 2006, samples were gathered from Acacia myrmecophytes [(Remarkable microfungi from Oaxaca of Acacia species) Part I]. In the present investigation [Part II], we collected microfungi from different parts of a variety of wild and cultivated higher plants belonging to the families Anacardiaceae, Caricaceae, Fabaceae, Moraceae, and Nyctaginacae. The microfungi found here live as parasites or saprophytes. Interestingly, the species Colletotrichum lindemuthianum (Sacc. and Magn.) Briosi and Cavara has repeatedly been used to cause fungal infections of Phaseolus lunatus leaves in laboratory experiments. We could now find the same fungus as parasite on the same host plants under field conditions showing that results obtained in the laboratory are also relevant in nature. Most of the fungal species collected belong to the classes Ascomycotina, Basidiomycotina and Deuteromycotina. Until now, some of the microfungi identified in this study have been rarely observed before or have been reported for the first time in Mexico, for example: Pestalotia acaciae Thüm. on Acacia collinsii Safford; Corynespora cassiicola (Berk. and M.A. Curtis) C.T. Wei on Carica papaya L.; Botryosphaeria ribis Grossenb. and Duggar and Cercosporella leucaenae (Raghu Ram and Mallaiah) U. Braun (new for Mexico) and Camptomeris leucaenae (F. Stevens and Dalbey) Syd. (new for Mexico) on Leucaena leucocephala (Lam.) de Wit.; Oidium clitoriae Narayanas. and K. Ramakr. and Phakopsora cf. pachyrhizi Sydow and Sydow (new for Mexico) on Clitoria ternatea L.; Botryosphaeria obtusa (Schw.) Shoemaker on Prosopis juliflora (Sw.) DC.; Cylindrocladium scoparium Morg. on Ficus benjamina L.; Acremonium sp. on Bougainvillea sp. All specimens are located in the herbarium ESS. Mycotheca Parva collection G.B. Feige and N. Ale-Agha.

Physiological response to cycling with both circular and noncircular chainrings

The purpose of this study was to compare physiological variables of endurance-trained cyclists riding with four different chainring designs: round, Shimano Biopace, and two engineered ellipse designs. The ellipse designated Eng10 had the crank arm oriented 10 degrees forward of the major (i.e. longer) axis. Eighty degrees further forward, along the minor axis, was the crank arm orientation for the second ellipse, Eng90. With the major to minor axis ratio of 22.9 cm/16.8 cm (1.36), both ellipses imposed a crank angular velocity variation of 27% relative to the highest velocity assuming constant chain velocity. Best described as a skewed ellipse (i.e., major and minor axes not perpendicular), the Biopace had a major to minor axis ratio of 1.09 thus giving a crank angular velocity variation of 8%. Eleven male cyclists rode at a high (80% of maximum VO2) and a low (60% of maximum VO2) workrate using each chainring. The study was conducted over four consecutive days with the presentation order of the chainrings randomized. Open circuit spirometry was used to collect continuous respiratory data. Heart rate, blood lactate, and cadence values also were measured. None of the physiological variables including rates of oxygen consumption showed significant differences among the chainrings. Thus, the gross efficiency of cycling was not improved by any of the noncircular chainrings. For cycling events where efficiency is a determinant of performance, the noncircular chainrings do not offer any advantage over round chainrings.

Characterization of pGA1, a new plasmid from Corynebacterium glutamicum LP-6

A new plasmid, pGA1, has been isolated from Corynebacterium glutamicum LP-6, and its detailed restriction map has been prepared. The 4.9-kb plasmid has a G + C content of 57%. It replicates in C. glutamicum ATCC13032 and is compatible with the three other plasmids, pCC1, pBL1 and pHM1519, commonly used for vector construction for amino acid-producing corynebacteria. Fusions of pGA1 with different Escherichia coli replicons (transferred from E. coli to Corynebacterium via transformation of spheroplasts or by filter mating experiments with intact cells) are shown to be suitable as shuttle plasmids; some of them are highly stable in C. glutamicum, even when propagated without any selection pressure.

An angular velocity profile in cycling derived from mechanical energy analysis

The contributions of this article are twofold. One is procedure for determining the angular velocity profile in seated cycling that maintains the total mechanical energy of both legs constant. A five-bar linkage model (thigh, shank, foot, crank and frame) of seated (fixed hip) cycling served for the derivation of the equations to compute potential and kinetic energies of the leg segments over a complete crank cycle. With experimentally collected pedal angle data as input, these equations were used to compute the total combined mechanical energy (sum of potential and kinetic energies of the segments of both legs) for constant angular velocity pedalling at 90 rpm. Total energy varied indicating the presence of internal work. Motivated by a desire to test the hypothesis that reducing internal work in cycling will reduce energy expenditure, a procedure was developed for determining the angular velocity profile that eliminated any change in total energy. Using data recorded from five subjects, this procedure was used to determine a reference profile for an average equivalent cadence of 90 rpm. The phase of this profile is such that highest and lowest angular velocities occur when the cranks are near vertical and horizontal respectively. The second contribution is the testing of the hypothesis that the reference angular velocity profile serves to effectively reduce internal work for the subjects whose data were used to develop this profile over the range of pedalling rates (80-100 rpm) naturally preferred. In this range, the internal work was decreased a minimum of 48% relative to the internal work associated with constant angular velocity pedalling. The acceptance of this hypothesis has relevance to the protocol for future experiments which explore the effect of reduced internal work on energy expenditure in cycling.

Heterogenic mRNAs with an identical protein-coding region of the human embryonic myosin alkali light chain in skeletal muscle cells

The formation of human myotubes in culture is accompanied by the induction of developmentally regulated, muscle-specific genes. We have studied the expression of human myosin light chain proteins and mRNAs during myogenesis in culture, in particular the skeletal embryonic myosin light chain 1 (MC1emb), which is indistinguishable from MLC1 of adult atrial cardiac muscle (MLC1A) as has been shown for rodent and bovine MLC1emb. We have identified distinct MLC1emb/MLC1A mRNAs in cultured human skeletal muscle cells that differ in their 5' and 3' untranslated regions but contain identical protein-coding regions. The alternative 3' untranslated region is detectable also in RNA of human atria. The different MLC1emb RNAs are likely to be encoded by one gene. It appears that the two MLC1emb 5' untranslated regions of the human gene are specific for man. In the mouse, only one 5' untranslated region of the MLC1emb gene has been detected.