Narda Murillo

Reduction of Spasticity With Repetitive Transcranial Magnetic Stimulation in Patients With Spinal Cord Injury

Objective. Spasticity with increased tone and spasms is frequent in patients after spinal cord injury (SCI). Damage to descending corticospinal pathways that normally exert spinal segmental control is thought to play an important causal role in spasticity. The authors examined whether the modulation of excitability of the primary motor cortex with high-frequency repetitive transcranial magnetic stimulation (rTMS) could modify lower limb spasticity in patients with incomplete SCI. Methods. Patients were assessed by the Modified Ashworth Scale, Visual Analogue Scale, and the Spinal Cord Injury Spasticity Evaluation Tool (SCI-SET) and neurophysiologically with measures of corticospinal and segmental excitability by the Hmax/Mmax, T reflex, and withdrawal reflex. Fifteen patients received 5 days of daily sessions of active (n = 14) or sham (n = 7) rTMS to the leg motor area (20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold for the biceps brachii muscle). Result. A significant clinical improvement in lower limb spasticity was observed in patients following active rTMS but not after sham stimulation.This improvement lasted for at least 1 week following the intervention. Neurophysiological studies did not change. Conclusions. High-frequency rTMS over the leg motor area can improve aspects of spasticity in patients with incomplete SCI.

Motivating, game-based stroke rehabilitation: a brief report.

Abstract Stroke-induced hemiparesis is a debilitating impairment that compromises ability to perform many activities of daily living (ADLs). Many new therapies for hemiparesis, although intriguing, require exceptional patient motivation and/or may be difficult to implement in some clinical situations. This brief report revisits a motivating, game-based rehabilitation modality reported nearly three decades ago that has heretofore been ignored. Pilot data, examining the feasibility and efficacy of the device, are presented.

Gait Training in Human Spinal Cord Injury Using Electromechanical Systems: Effect of Device Type and Patient Characteristics

OBJECTIVE To report the clinical improvements in spinal cord injury (SCI) patients associated with intensive gait training using electromechanical systems according to patient characteristics. DESIGN Prospective longitudinal study. SETTING Inpatient SCI rehabilitation center. PARTICIPANTS Adults with SCI (n=130). INTERVENTION Patients received locomotor training with 2 different electromechanical devices, 5 days per week for 8 weeks. MAIN OUTCOME MEASURES Lower-extremity motor score, Walking Index for Spinal Cord Injury, and 10-meter walking test data were collected at the baseline, midpoint, and end of the program. Patients were stratified according to the American Spinal Injury Association (ASIA) category, time since injury, and injury etiology. A subgroup of traumatic ASIA grade C and D patients were compared with data obtained from the European Multicenter Study about Human Spinal Cord Injury (EM-SCI). RESULTS One hundred and five patients completed the program. Significant gains in lower-limb motor function and gait were observed for both types of electromechanical device systems, to a similar degree. The greatest rate of improvement was shown in the motor incomplete SCI patients, and for patients <6 months postinjury. The positive response associated with training was not affected by injury etiology, age, sex, or lesion level. The trajectory of improvement was significantly enhanced relative to patients receiving the conventional standard of care without electromechanical systems (EM-SCI). CONCLUSIONS The use of electromechanical systems for intensive gait training in SCI is associated with a marked improvement in lower-limb motor function and gait across a diverse range of patients and is most evident in motor incomplete patients, and for patients who begin the regimen early in the recovery process.

Motor and gait improvement in patients with incomplete spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation.

OBJECTIVE To assess the effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) on lower extremities motor score (LEMS) and gait in patients with motor incomplete spinal cord injury (SCI). METHOD The prospective longitudinal randomized, double-blind study assessed 17 SCI patients ASIA D. We assessed LEMS, modified Ashworth Scale (MAS), 10-m walking test (10MWT), Walking Index for SCI (WISCI II) scale, step length, cadence, and Timed Up and Go (TUG) test at baseline, after the last of 15 daily sessions of rTMS and 2 weeks later. Patients were randomized to active rTMS or sham stimulation. Three patients from the initial group of 10 randomized to sham stimulation entered the active rTMS group after a 3-week washout period. Therefore a total of 10 patients completed each study condition. Both groups were homogeneous for age, gender, time since injury, etiology, and ASIA scale. Active rTMS consisted of 15 days of daily sessions of 20 trains of 40 pulses at 20 Hz and an intensity of 90% of resting motor threshold. rTMS was applied with a double cone coil to the leg motor area. RESULTS There was a significant improvement in LEMS in the active group (28.4 at baseline and 33.2 after stimulation; P = .004) but not in the sham group (29.6 at baseline, and 30.9 after stimulation; P = .6). The active group also showed significant improvements in the MAS, 10MWT, cadence, step length, and TUG, and these improvements were maintained 2 weeks later. Following sham stimulation, significant improvement was found only for step length and TUG. No significant changes were observed in the WISCI II scale in either group. CONCLUSION High-frequency rTMS over the leg motor area can improve LEMS, spasticity, and gait in patients with motor incomplete SCI.

Decrease of spasticity with muscle vibration in patients with spinal cord injury

OBJECTIVE Spasticity is common after spinal cord injury (SCI). Exaggerated tendon jerks, clonus, and spasms are key features of spasticity that result from hyperexcitability of the stretch reflex circuit. Here we studied the effects of vibration on the rectus femoris muscle (RF) on clinical and electrophysiological measures of spasticity in the leg. METHODS Nineteen SCI patients with spasticity and nine healthy subjects were studied at baseline and under stimulation (vibration at 50 Hz during 10 min on the thigh). Neurophysiological studies included evaluation of the soleus T wave and Hmax/Mmax ratio. Clinical measurements of spasticity were the score in the Modified Ashworth Scale (MAS), range of motion (ROM), and duration and frequency of clonus. RESULTS Patients with incomplete SCI (iSCI) presented higher number of cycles and longer duration of clonus than patients with complete SCI (cSCI). The Hmax/Mmax ratio and T wave amplitude at baseline were significantly larger in iSCI patients than in cSCI or healthy subjects. During vibration, we found a significant reduction of MAS and duration of clonus, and an increase in ROM, in all patients as a group. The Hmax/Mmax ratio and the T wave amplitude decreased significantly in both, patients and controls. CONCLUSIONS Prolonged vibration on proximal lower extremity muscles decreased limb spasticity in patients with spinal cord injury, regardless of whether the lesion is complete or incomplete. SIGNIFICANCE Muscle vibration may be useful for physical therapy, by facilitating passive and active movements of the extremities in spastic SCI patients.

RETRACTED: Effects of High-Frequency Repetitive Transcranial Magnetic Stimulation on Motor and Gait Improvement in Incomplete Spinal Cord Injury Patients:

Kumru H, Benito J, Murillo N, et al. Effects of high-frequency repetitive transcranial magnetic stimulation on motor and gait improvement in incomplete spinal cord injury patients. Neurorehabil & Neural Repair. 2013;27:421-429. Original DOI: 10.1177/1545968312471901. The above article has been retracted because of substantial overlap with a previously published article in another journal.

Transcranial direct current stimulation is not effective in the motor strength and gait recovery following motor incomplete spinal cord injury during Lokomat® gait training

OBJECTIVE/HYPOTHESIS Transcranial direct current stimulation (tDCS) is a potential tool to improve motor recovery in patients with neurological disorders. Safety and efficacy of this procedure for lower extremity motor strengthe and gait function in motor incomplete spinal cord injury (SCI) have not yet been addressed. The aim of this study is to optimize the functional outcome in early phases of gait rehabilitation assisted by Lokomat(®) in motor incomplete SCI patients using tDCS as an additional treatment to physical therapy. METHODS We performed in a SCI unit a single-centre randomized, double-blind, sham-controlled study to investigate safety and efficacy of anodal tDCS of over leg motor cortex in motor incomplete SCI patients. Twenty-four SCI patients received either daily sessions of anodal tDCS (n=12) at 2mA for 20min to the vertex (leg motor cortex) during twenty days or sham tDCS (n=12). Motor deficit was assessed by the lower extremity motor score (LEMS) and for gait function: ten meter walking test (10MWT) and Walking Index for SCI (WISCI II) at baseline, after last tDCS session (after 4 weeks of stimulation), and after 8 weeks (from baseline) for follow-up. RESULTS No side effects were detected during either tDCS or sham. In both groups, there was a significant improvement in LEMS (p<0.03), which did not significantly differ when comparing anodal and sham tDCS groups. During follow-up, in both group 5 of 12 patients could perform gait, without significant differences in gait velocity, cadence, step length and WISCI-II between both groups. CONCLUSION Combination twenty sessions of daily tDCS to the leg motor cortex and Lokomat(®) gait training appear to be safe in motor incomplete SCI patients. There was an expected improvement in both LEMS and gait scales however, did not differ between patients treated with anodal or sham tDCS.

Recovery of assisted overground stepping in a patient with chronic motor complete spinal cord injury: A case report

BACKGROUND Clinical studies have shown that after incomplete spinal cord lesions at the thoracic level, patients can develop functional gait patterns through gait training. To date, however, training has been ineffective in producing gait in patients with clinically motor complete spinal cord lesions. OBJECTIVE Here we report a patient with chronic motor complete spinal cord injury who regained locomotor function with assistance after intensive gait rehabilitation treatment. METHODS A fifteen year old female patient had sustained motor complete spinal cord injury (T6, AIS B) 2 years earlier, with severe bilateral extensor spasticity, and ineffective previous gait training with robotic systems. The therapy consisted of two months of gait training with a robotic system combined with bilateral functional electrical stimulation (FES) of the peroneal nerve, and one month of gait training with a special walker and FES of the left leg and occasionally on the right leg, due to flexor reflex could sometimes be initiated by the patient in the right leg without electrical stimulation. Neurophysiological studies and ten metres test were done. RESULTS At the end of training, the patient was able to cover a distance of 200 metres without FES with a walker and assistance from a physiotherapist, who pulled the walker with each step to help her to accomplish effective overground stepping. Motor and somatosensory evoked potentials were absent in the lower limbs. CONCLUSION Even after a motor complete lesion with some preservation of sensory pathways, the spinal cord may be able to retain some of its locomotor function through intensive gait rehabilitation.

Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics

Study designProspective quasi-experimental study, pre- and post-design.ObjectivesAssess safety, feasibility, training characteristics and changes in gait function for persons with spinal cord injury (SCI) using the robotic exoskeletons from Ekso Bionics.SettingNine European rehabilitation centres.MethodsRobotic exoskeleton gait training, three times weekly over 8 weeks. Time upright, time walking and steps in the device (training characteristics) were recorded longitudinally. Gait and neurological function were measured by 10 Metre Walk Test (10 MWT), Timed Up and Go (TUG), Berg Balance Scale (BBS), Walking Index for Spinal Cord Injury (WISCI) II and Lower Extremity Motor Score (LEMS).ResultsFifty-two participants completed the training protocol. Median age: 35.8 years (IQR 27.5–52.5), men/women: N = 36/16, neurological level of injury: C1-L2 and severity: AIS A–D (American Spinal Injury Association Impairment Scale). Time since injury (TSI) < 1 year, N = 25; > 1 year, N = 27.No serious adverse events occurred. Three participants dropped out following ankle swelling (overuse injury). Four participants sustained a Category II pressure ulcer at contact points with the device but completed the study and skin normalized. Training characteristics increased significantly for all subgroups. The number of participants with TSI < 1 year and gait function increased from 20 to 56% (P = 0.004) and 10MWT, TUG, BBS and LEMS results improved (P < 0.05). The number of participants with TSI > 1 year and gait function, increased from 41 to 44% and TUG and BBS results improved (P < 0.05).ConclusionsExoskeleton training was generally safe and feasible in a heterogeneous sample of persons with SCI. Results indicate potential benefits on gait function and balance.

Influence of spinal cord lesion level and severity on H-reflex excitability and recovery curve

Changes in spinal reflexes can result from alterations in the spinal cord and descending pathways. We studied whether H‐reflex excitability and its recovery depend on the level and/or severity of spinal cord injury (SCI).