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Implanted systems have the advantage of being able to stimulate the hip flexors, and therefore, to provide better muscle selectivity and potentially better gait patterns. In the acute stage of stroke recovery, the use of cyclic electrical stimulation has been seen to increase the isometric strength of wrist extensors.

In order to increase strength of wrist extensors, there must be a degree of motor function at the wrist spared following the stroke and have significant hemiplegia. Patients who will elicit benefits of cyclic electrical stimulation of the wrist extensors must be highly motivated to follow through with treatment , After 8 weeks of electrical stimulation, an increase in grip strength can be apparent. Many scales, which assess the level of disability of the upper extremities following a stroke, use grip strength as a common item.

Therefore, increasing strength of wrist extensors will decrease the level of upper extremity disability. Patients with hemiplegia following a stroke commonly experience shoulder pain and subluxation; both of which will interfere with the rehabilitation process. Functional electrical stimulation has been found to be effective for the management of pain and reduction of shoulder subluxation, as well as accelerating the degree and rate of motor recovery. Furthermore, the benefits of FES are maintained over time; research has demonstrated that the benefits are maintained for at least 24 months.

Drop foot is a common symptom in hemiplegia , characterized by a lack of dorsiflexion during the swing phase of gait, resulting in short, shuffling strides. It has been shown that FES can be used to effectively compensate for the drop foot during the swing phase of the gait. At the moment just before the heel off phase of gait occurs, the stimulator delivers a stimulus to the common peroneal nerve, which results in contraction of the muscles responsible for dorsiflexion.

There are currently a number of drop foot stimulators that use surface and implanted FES technologies. The term "orthotic effect" can be used to describe the immediate improvement in function observed when the individual switches on their FES device compared to unassisted walking. This improvement disappears as soon as the person switches off their FES device. In contrast, a "training" or "therapeutic effect" is used to describe a long term improvement or restoration of function following a period of using the device which is still present even when the device is switched off.

A further complication to measuring an orthotic effect and any long term training or therapeutic effects is the presence of a so-called "temporary carry over effect". Liberson et al. It has been hypothesised that this temporary improvement in function may be linked to a long term training or therapeutic effect.

Hemiparetic stroke patients, who are impacted by the denervation, muscular atrophy, and spasticity, typically experience an abnormal gait pattern due to muscular weakness and the incapacity to voluntary contract certain ankle and hip muscles at the appropriate walking phase.

A systematic review conducted in on the use of FES in chronic stroke included seven randomized controlled trials with a total of participants. The review found a small treatment effect for using FES for the 6 minute walking test. FES has also been found to be useful for treating foot drop in people with multiple sclerosis. The first use was reported in by Carnstam et al. FES has been found to be useful for treating the symptoms of cerebral palsy.

Improvements were found in gastrocnemius spasticity, community mobility and balance skills. The review further concludes that adverse events were rare and the technology is safe and well tolerated by this population.

NICE have stated that "current evidence on the safety and efficacy in terms of improving gait of functional electrical stimulation FES for drop foot of central neurological origin appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit". Notes This article is a direct transclusion of the Wikipedia article and therefore may not meet the same editing standards as LIMSwiki. Jump to: navigation , search. This section needs more medical references for verification or relies too heavily on primary sources. Please review the contents of the section and add the appropriate references if you can.

Unsourced or poorly sourced material may be challenged and removed. December This article includes a list of references , but its sources remain unclear because it has insufficient inline citations. Please help to improve this article by introducing more precise citations. February Learn how and when to remove this template message. Popovic, K. Masani and S.

Rymer, T. Nef and V. Dietz, Ed. Springer Science Publishers in November Claudia et al. Nagai, C. Marquez-Chin, and M. Popovic, "Why is functional electrical stimulation therapy capable of restoring motor function following severe injury to the central nervous system? Popovic and T. Wnek and G.

Bowlin, Eds. Simulation of the three-dimensional electrical field in the course of functional electrical stimulation. Artificial Organs —, Other recent and exciting advancements in spinal cord injury research to maximize spinal cord injury recovery in patients include: The creation of 3D printed medical devices that would serve as a platform of specialized neuronal stem cells; The grafting of cultured spinal cord neural stem cells NSCs in rats with SCIs; Gene therapy research that helped restore hand function in rats with spinal cord injuries; The use of olfactory ensheathing cells to trigger spinal cord nerve regeneration; Want to learn more about breakthroughs in spinal cord injury research?

Find everything you need to learn more about your injury, locate a doctor or treatment center, or discover financial relief to support you through this difficult time. Speak to an Expert: Spinal Cord Team December 01, Tiffiny Carlson March 21, Topics: Spinal Cord Injury, Treatment.

Spinal Cord Team September 17, Spinal Cord Injury. Brain Injury. Finding Treatment. Legal Options. About Us. Learn More About SpinalCord. Recent Posts. There is a thin line between that which constitutes a benefit versus that which constitutes a detriment and could be easily crossed by either mode of stimulation. Presently, epidural and pharmacological stimulation of the isolated spinal cord is still in an experimental stage. The current approaches of stimulation techniques are unlikely to be beneficial to a majority of patients with spinal cord injury Domingo et al.

With increasing severity especially complete lesions , where both excitatory and inhibitory control of spinal networks is lacking, artificially induced motor function is difficult to use by an individual. Furthermore, the aforementioned stimulation technique is restricted to lower limb function where restricted mobility can be provided by the use of a wheelchair. Nevertheless, enhancing locomotor function with electrical stimulation remains a promising research direction. A partial repair of the damaged spinal cord could avoid the problems of stimulation techniques following complete spinal cord injury.

During the past decades, a number of approaches to induce regeneration in the spinal cord were moderately successful in rodent models. The best cell candidate for a transplantation-based treatment of spinal cord injury remains a matter of investigation Tetzlaff et al. Schwann cells have been studied for many years and have been demonstrated to reliably form tissue bridges following complete lesions of the spinal cord Bunge and Pearse, Other types of grafts are auto-transplantation of olfactory ensheathing or stem cells Fortun et al.

Also these cells are known to be permissive for the outgrowth of lesioned axons.

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Functional priorities, assistive technology, and brain-computer interfaces after spinal cord injury

In the case of olfactory ensheathing cells, neither negative nor beneficial effects were found in individuals with motor complete spinal cord injury Mackay-Sim et al. Also results from a larger group of individuals examined in China did not show signs of motor recovery cf. Dobkin et al. Lastly these trials were not able to detect smaller but relevant negative or positive effects because of the small number of subjects included Mackay-Sim et al.

Cell grafts on their own not even stem cells , will likely not be sufficient to promote substantial repair of the human spinal cord because axonal regeneration beyond a graft is rarely observed in animal models. However, cell grafts can be an essential factor for combinations with other regeneration promoting treatments Fouad et al.


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More recently alternative sources from skin-derived precursor cells show promise as they effectively promote regeneration and remyelination of axons without co-treatments in rodents Biernaskie et al. Also, other cell grafts such as oligodendrocyte precursor cells might have potential in remyelinating spared axons thereby contributing to recovery Karimi-Abdolrazaee et al.

The excitement about the use of stem cells has taken a major hit by the interruption of the GERON trial and the fact that the tumour risk of such a treatment cannot be ignored. Nevertheless, an encouraging result of a study grafting embryonic tissue comes from the Tuszynski laboratory Lu et al.

Functional Electrical Stimulation (FES)

This approach shows a significant outgrow of axons from embryonic-derived neurons over longer distances in the adult rodent spinal cord. The key to the success of this study might have been the use of the embryonic stem cells in combination with a medium involving growth factors leading to a longer survival of the cells. Pharmacologically, a promising candidate for promoting repair regeneration and plasticity is chondroitinase ABC, a chondroitin sulphate proteoglycan digesting enzyme Fawcett, This enzyme has repeatedly demonstrated its ability to allow axonal regeneration and plasticity in different animal models, currently making it one of the most appreciated experimental treatments.

Recently, a phase I trial has been successfully completed. Many experimental treatments address the inhibitory environment of the adult CNS and result in only moderate axonal regeneration. The results of manipulating this pathway using genetically modified mice indicate that regeneration of corticospinal tract fibres following incomplete spinal lesions is possible Liu et al.

For the success of all regeneration- and plasticity inducing therapies it will be of crucial importance that axons form correct connections. However, to demonstrate that new connections are functionally meaningful is challenging. In this study the rewiring was paralleled by significant recovery. Furthermore, it has been demonstrated that adaptations in descending tracts especially collateral sprouting are contributing to spontaneous and training-induced recovery Weidner et al.

Over 30 years of research to repair the injured spinal cord did not result in the successful translation of treatments that promote functional recovery from animal models to the clinical setting. This lack of clinical success stands in contrast with many promising results in animal models that have been reported. This discrepancy is raising doubts about the quality of reports from animal models that are frequently flawed, for example, by a reporting bias because of missing data and a lack of negative results Ioannidis, ; Hunter, But, it would be wrong to put the blame exclusively on inadequate spinal cord injury animal models.

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One reason for the lack of successful translation concerns unrealistic expectations, such as anticipating a cure, although only small benefits are found in animal models. Such expectations are repeatedly fuelled by overstated headlines in the media Bubela and Caulfield, Considering the relatively small functional benefits of treatments found in standardized and controlled animal models of spinal cord injury, it is not surprising that when these treatments are applied in the clinical setting, where a much higher variability in lesion size and location exists, no effects are found.

Thus, in complete spinal cord transection these treatments can only promote benefits if the lesion site is bridged. In clinical trials of spinal cord injury, typically the first safety phase is performed in individuals with complete lesions where usually no sufficient tissue bridges exist Dietz and Curt, Combinatorial treatments addressing more than one of these impediments for neurite growth currently have a high priority in basic research. However, such treatments are challenging, due not only to technical difficulties, but also to unpredictable treatment interactions and the necessity of a large number of controls.

Limitations of animal models also include different projections of spinal tracts in different species determining the degree of recovery. For example, when comparing primates to rodents the corticospinal tract has a higher degree of midline crossing collaterals, enabling a higher degree of recovery in primates as compared to rodents Rosenzweig et al. In addition, quadrupedal locomotion allows more post-lesion activities and thus self-training compared with bipedal walking in humans Fouad et al.

Furthermore, treatments in animal models are frequently applied directly after injury, which is clinically unrealistic , with injury types typically not found in patients e. Metz et al. Beyond these limitations, results from animal models frequently cannot be repeated in the same animal model Steward et al. Such deficiencies include a low statistical power of animal experiments with relatively small numbers of animals, resulting in the probability of false positive results Ioannidis, and a bias to publish such positive results Sena et al.

Another bias might occur because of an invested interest in a treatment with the consequence that scientists are reluctant to publish negative results of a therapy.

This idea was fostered by the results of a survey performed recently Kwon et al. In general, it has to be recognized that not all scientific achievements in basic research in spinal cord repair do necessarily advance the field towards clinical trials. Treatments designed to promote axonal regrowth have a substantial risk potential e.

Therefore, progress has to be made in understanding the physiological changes in the injured spinal cord as well as the drug interactions and possible side effects of a treatment.

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Such contributions are important for developing safe and reliable treatments in the future. The clinicaltrials. Axon regeneration versus sprouting after a spinal cord injury. The figure summarizes the mechanisms of regeneration and sprouting after a spinal tract damage. A An injury severs some axons while sparing others. B Regeneration is the growth from the injured axonal tips. Regenerating axons can grow through or around a lesion site. C Sprouting of spared i. They often sprout into a denervated area, in response to an injury elsewhere in the CNS.

D Sprouting can also occur from uninjured portions of injured neurons i. During the past 20 years, basic and clinical research activities have strongly advanced the field of spinal cord research and, consequently, of rehabilitating people with spinal cord injury. Principles to promote neuroplasticity derived from basic research have become successful in terms of their translation to the human condition and will further be refined and supplemented by advanced technology. Treatments directed at improving function by pharmacological or electrical stimulation are on the verge of translation, but face substantial challenges.

Such challenges are found throughout the clinical sciences e. Nevertheless, the knowledge gained by basic research, e. This makes the perspectives for some restoration of lost functions even after motor complete spinal cord injury promising. In people with incomplete spinal cord injury neuroplasticity can be facilitated and refined by training of upper and lower limb movements with the goal to individually optimize the functional outcome. The prognosis of outcome after injury by clinical and electrophysiological examinations allows an early selection of appropriate training approaches.

These should focus on relearning specific everyday movements. An effective rehabilitation of sensorimotor systems is based on physiological requirements that lead to a meaningful muscle activation. Stimulation approaches might facilitate stepping but hardly upper limb movements. Repair interventions are as yet, not successful. Thus, basic research needs to continue to develop, to repeat and to combine treatments with the aim to repair the injured spinal cord. Lastly, guidelines are needed regarding what should be translated and what can realistically be expected from reliable and safe treatments Kwon et al.

We thank Dr. Monica Gorassini, Dr. Jaynie Yang, Dr. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents. Clinical aspects of rehabilitation: role of neuroplasticity.

References

Preclinical approaches to restore function. Restoration of sensorimotor functions after spinal cord injury Volker Dietz. Oxford Academic. Google Scholar. Karim Fouad. Cite Citation. Permissions Icon Permissions. Abstract The purpose of this review is to discuss the achievements and perspectives regarding rehabilitation of sensorimotor functions after spinal cord injury. Figure 1. Open in new tab Download slide.

Figure 2. Table 1. Remy-Neris et al. Open in new tab. Figure 3. Comparison of training methods to improve walking in persons with chronic spinal cord injury: a randomized clinical trial. Search ADS. Functional electrical stimulation enhancement of upper extremity functional recovery during stroke rehabilitation: a pilot study. The role of rehabilitation in the recovery of walking in the neurological population. Initiation and modulation of the locomotor pattern in the adult chronic spinal cat by noradrenergic, serotonergic and dopaminergic drugs.

The injured spinal cord spontaneously forms a new intraspinal circuit in adult rats. Characteristics and mechanisms of locomotion induced by intraspinal microstimulation and dorsal root stimulation in spinal cats. Undirected compensatory plasticity contributes to neuronal dysfunction after severe spinal cord injury. Gait training in human spinal cord injury using electromechanical systems: effect of device type and patient characteristics.

Skin-derived precursors generate myelinating Schwann cells that promote remyelination and functional recovery after contusion spinal cord injury. Down-regulation of the potassium-chloride cotransporter KCC2 contributes to spasticity after spinal cord injury. A comparison of newspaper stories and peer-reviewed research papers. Hindlimb immobilization in a wheelchair alters functional recovery following contusive spinal cord injury in the adult rat.

Activation of the central pattern generators for locomotion by serotonin and excitatory amino acids in neonatal rat. Operant conditioning of H-reflex can correct a locomotor abnormality after spinal cord injury in rats. Spinal associative stimulation: a non-invasive stimulation paradigm to modulate spinal excitability. Transformation of nonfunctional spinal circuits into functional state after the loss of brain input. Recovery of supraspinal control of stepping via indirect propriospinal relay connections after spinal cord injury.

Changes of non-affected upper limb representation in paraplegic patients as assessed by fMRI. Providing the clinical basis for new interventional therapies: refined diagnosis and assessment of recovery after spinal cord injury. Recovery from a spinal cord injury: significance of compensation, neural plasticity and repair. Arm movements can increase leg muscle activity during sub-maximal recumbent stepping in neurologically intact individuals.

Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats. Gait recovery is not associated with changes in the temporal patterning of muscle activity during treadmill walking in post-stroke hemiparesis. Google Preview. Changes in spinal reflex and locomotor activity after a complete spinal cord injury: a common mechanism? Degradation of neuronal function following a spinal cord injury: mechanisms and countermeasures. Locomotor activity in spinal man: significance of afferent input from joint and load receptors.

Spastic movement disorder: impaired reflex function and altered muscle mechanics. Weight-supported treadmill vs overground training for walking after acute incomplete spinal cord injury. Should body weight-supported treadmill training and robotic-assistive steppers for locomotor training trot back to the starting gate? Cellular transplants in China: observational study from the largest human experiment in chronic spinal cord injury.

A systematic review on the effects of pharmacological agents on walking function in people with spinal cord injury. Does functional electrical stimulation for foot drop strengthen corticospinal connections? Functional neurological recovery after spinal cord injury is impaired in patients with infections. Recovery of locomotor activity in the adult chronic spinal rat after sublesional transplantation of embryonic nervous cells: specific role of serotonergic neurons.

Influence of a locomotor training approach on walking speed and distance in people with chronic spinal cord injury: a randomized clinical trial.

How Electrical Stimulation Helps Spinal Cord Injury Recovery

Combinatorial strategies with Schwann cell transplantation to improve repair of the injured spinal cord. Combining Schwann cell bridges and olfactory-ensheathing glia grafts with chondroitinase promotes locomotor recovery after complete transection of the spinal cord. Corticomotor representation to a human forearm muscle changes following cervical spinal cord injury.

Chondroitinase ABC treatment opens a window of opportunity for task-specific rehabilitation.

Patient with Spinal Cord Injury using the Xcite Functional Electrical Stimulation (FES) System.

Initiation of locomotor activity in spinal cats by epidural stimulation of the spinal cord.