The authors would like to thank Gabrielle Leyden for revising the final draft of this paper.

1. Patient Selection
<ol>
	<li>Make a diagnosis of FBSS20.</li>
	<li>Be sure that the FBSS patient meets all the inclusion criteria before being accepted for an SCS trial:
	<ol>
		<li>Chronic low back pain and/or radicular leg pain that were refractory to optimal medical therapy for a minimum of 6 months.</li>
		<li>Persistent pain despite 3 types of pharmacological treatments (paracetamol, non-steroidal anti-inflammatory drugs, opioids, antidepressant medications, anticonvulsant medications, etc.).</li>
		<li>Lemniscal pathways must remain at least partially intact (for paresthesia coverage of the painful area).</li>
	</ol>
	</li>
	<li>Rule out exclusion criteria for SCS in FBSS patients such as active infection, drug addiction or ongoing withdrawal, psychological contraindications, documented mechanical causes of low BP (discogenic pain, spondylolisthesis, spinal instability, and posterior joint osteoarthritis), and coagulopathy (due to risk of bleeding and epidural hematoma). Make sure that no coagulopathy is present by asking relevant questions, examining the patient and, if necessary, checking relevant blood tests for coagulopathy.</li>
</ol>
2. Neuromodulation Specialist
<ol>
	<li>If the FBSS patient meets the criteria for SCS, refer him to the neuromodulation specialist (NMS). 
	NOTE: The neuromodulation specialist in our team is a nurse. He is fully dedicated to pain and neuromodulation and is the coordinator of the pluridisciplinary team, which includes a psychologist, a physiotherapist, and a specialist pain nurse.</li>
	<li>Describe the anatomy of the pain pathways to the patient and explain the difference between nociceptive and neuropathic pain. Explain the sites of action of the different analgesic and co-analgesic medications. 
	NOTE: It is important that the patient understands the nature of neuropathic pain and can differentiate it from nociceptive pain. Once the patient has understood the physiology of their neuropathic pain, they are ready to learn about SCS.</li>
	<li>Explain to the patient the theoretical concept of SCS. The technique is believed to inhibit chronic pain by stimulating the large-diameter afferent nerve fibers in the spinal cord, in accordance with the gate control theory of pain.</li>
	<li>Measure the Visual Analog Scales (VAS) score21 for leg and back pain.</li>
	<li>Explain the objectives of the therapy:
	<ol>
		<li>Paresthesia coverage of the painful area of 50 to 70%.</li>
		<li>Reduction of pain (VAS score).</li>
		<li>Reduction in analgesic and co-analgesic medications.</li>
		<li>Improvement in the quality of sleep.</li>
		<li>Improvement in the quality of life.</li>
		<li>Improvement in the distance walked.</li>
	</ol>
	</li>
	<li>Explain the different components of an SCS device (epidural lead, internal pulse generator, and the extension cable connecting the lead to the IPG) and let the patient manipulate them to understand the system better.</li>
</ol>
3. Creation of the Health Insurance File by the NMS
<ol>
	<li>Describe in this file the characteristics of the patient&#39;s pain, quality of life, and quality of sleep, but also the patient&#39;s activities, walked distance, and analgesic and co-analgesic consumption. 
	NOTE: Under Belgian law, psychiatric evaluation is mandatory before any surgery to implant a foreign body. The psychiatrist has to rule out any psychiatric disorder and evaluate the patient&#39;s functional capacities in order to be able to accept and live with a foreign body.</li>
	<li>Attach the patient&#39;s medical record and the psychiatric evaluation to the Health Insurance File.</li>
</ol>
4. Implantation of the Multicolumn Lead
<ol>
	<li>Obtain the patient&#39;s informed consent after explaining the details of the surgical procedure, including the complications (infection 3&#8211;6%; serious neurological complications 0.54&#8211;1.71%; epidural hematoma 0.19&#8211;0.63%; spinal cord injury 0.022&#8211;0.067%; and cerebrospinal fluid leakage 0.05&#8211;0.001%)22. 
	NOTE: The long testing period required in Belgium is presumed to be the main reason for the higher infection rate (11%) observed in our institution, and we are currently trying to address this issue. This must be explained to the patient.</li>
	<li>In addition to the above risks, which are similar to those associated with other spinal procedures, explain the other risks normally associated with the use of an implant, such as allergic or immune system responses to the implanted materials; lead, extension, or neurostimulator erosion through the skin or migration; and formation of reactive tissue around the lead in the epidural space that can result in delayed spinal cord compression and paralysis, requiring surgical intervention. Time to onset can range from weeks to many years after implant. 
	NOTE: The neurological complication rates for percutaneous dorsal column stimulation leads are slightly higher (infection 3&#8211;6%; serious neurological complications 0&#8211;2.35%; epidural hematoma 0.75%; spinal cord injury 0.03&#8211;2.35%; and cerebrospinal fluid leakage 0.3%)22.</li>
	<li>If the patient doesn&#39;t have any contraindication, conduct an MRI to rule out any anomaly of the conus medullaris projection such as spinal dysraphism or other congenital spinal cord anomalies23.</li>
	<li>Perform antibiotic prophylaxis 30 min before incision using a single intravenous (IV) dose of Cefazolin, 50 mg/kg, with a maximum of 2 gm, through a 16 G needle placed in a peripheral route.</li>
	<li>With the patient under general anesthesia (use 0.1 &#181;g/kg Sunfentanil, 2 mg/kg Propolipid 1%, 0.3 mg/kg Ketamine Hydrochloride (see Table of Materials), and 0.3 mg/kg Rocuronium) and in the prone position, define the incision site between the spinous processes of T10 and T11 under fluoroscopic assistance.</li>
	<li>Infiltrate the incision site with 5 mL of a 20 mL solution of 0.5% Bupivacaine and 1:200,000 adrenaline (see Table of Materials).</li>
	<li>Incise until the thoracic aponeuroses are revealed.</li>
	<li>Dissect the paravertebral musculature on both sides of T10&#39;s supraspinous process and place the retractor.</li>
	<li>Resect the supraspinous and interspinous ligaments and dissect the lamina of T10 (5 mm on each side and 5 mm in the craniocaudal direction).</li>
	<li>Before inserting the lead, perform a partial laminectomy of T10 to create enough space to allow the insertion of the lead (no need to remove the entire lamina).</li>
	<li>Insert the phantom lead into the epidural space, while keeping the insertion of the flavum ligament on the upper part of the T11 lamina intact. 
	NOTE: This T11 lamina is used as a guide for the insertion of the lead into the epidural space.</li>
	<li>Place the lead as medially as possible under fluoroscopic guidance. The final lead&#39;s position is reached when placed midline in the projection of the bodies of T8&#8211;T9 under fluoroscopic control.</li>
	<li>Fix the lead to the interspinous ligament of T11 by doing a single interrupted stitch.</li>
	<li>Tunnel the extensions from your operative field to the lateral side of the back (often the right one) by using the tunneling tool provided by the company, and then connect them to the lead.</li>
	<li>Check fluoroscopically to be sure the lead has not moved and is still in the epidural space, midline, in the projection of T8&#8211;T9.</li>
	<li>Remove the retractor and make sure there is no bleeding.</li>
	<li>Suture the musculo-aponeurotic layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Connect the two intrinsic external extensions to the two extrinsic external extensions. Tunnel them in the subcutaneous fat in such a way that they exit through the skin 15 cm laterally to the incision site. 
	NOTE: The choice of the side is discussed preoperatively with the patient and depends on the implantation location of the internal pulse generator.</li>
	<li>Wrap the intrinsic and extrinsic extensions and suture the subcutaneous layer by means of simple interrupted stitches of braided synthetic absorbable suture material (see Table of Materials).</li>
	<li>Make a dermic subcuticular suture using finer absorbable 3/0 suture material (see Table of Materials) and apply antiseptic and bandages. During this step, administer a single IV dose of 1g Paracetamol and 100 mg Tradonal.</li>
</ol>
5. Postoperative Trial
<ol>
	<li>When the lead is placed, connect it to an external stimulator for a period of four weeks. 
	NOTE: This long test period is required by the Belgian law as a condition to reimburse the implantation of the pulse generator during a second operation.</li>
	<li>Begin the programming sessions a few hours after surgery. The objective of the therapy is to cover the painful area by pleasant paresthesia.</li>
	<li>Connect the external neurostimulator to the extrinsic external lead extensions.</li>
	<li>Place the clinician programmer on the external neurostimulator. Turn the clinician programmer on and then turn the neurostimulation on. Start by setting the pulse width (PW) to 260 &#181;s, at a rate of 60 Hz.</li>
	<li>If LP was bilateral, perform a first screening using a guarded cathode (+-+), starting with the top-left tripolar longitudinal stimulation configuration (Figure 1), in order to identify the laterality of the lead (right/left).</li>
	<li>Perform a rapid scan of the left side with the four remaining left-side tripolar longitudinal stimulation configurations (Figure 2). An idea of the painful metameric level is determined during this unilateral screening. Thereafter, scan the right side following the same scheme (Figure 3).</li>
	<li>Finally, activate the stimulation configuration(s) allowing better paresthesia coverage of the painful leg area(s). 
	NOTE: If there is bilateral LP, two different stimulation configurations must be programmed to obtain optimal paresthesia coverage of the two painful areas.</li>
	<li>For back pain, test a transverse tripolar configuration at the top of the lead first, using the guarded cathode configuration (Figure 4). If this configuration gives insufficient paresthesia coverage, test a &#34;half flower-like pattern&#34; configuration of four anodes around a cathode (Figure 4). If this configuration does not provide sufficient paresthesia coverage and/or pain suppression again, use a tripolar longitudinal configuration in order to verify possible bilateral stimulation by one channel (Figure 4).</li>
	<li>Fine-tune back pain area coverage by increasing PW to 450 &#181;s. This makes it possible to enlarge the area of stimulation. Adjust the pulse rate between 40 and 60 Hz to obtain the most satisfying paresthesia coverage of the painful area. 
	NOTE: These settings are based on experience with this multicolumn surgical lead and may of course vary with a different device or stimulation strategy (high-intensity stimulation, for example). For more detailed instructions, please consult the Programmer Quick Guide24.</li>
	<li>Ensure close follow-up (at least once a week) of the patient during the trial phase (1 month in Belgium) to check appropriate wound healing and optimize paresthesia coverage by repeating Steps 5.7, 5.8 and 5.9. Use sterile technique bandage changes22. Educate the patient about the signs and symptoms of an emerging surgical site infection.</li>
	<li>At the end of the trial period, use sharp scissors to cut the external extension flush with the skin in order to reduce the risk of infection until the next surgical procedure.</li>
</ol>
6. Implantation of the Internal Pulse Generator
<ol>
	<li>If pain relief is higher than 50% at the end of the one-month trial period (Belgian reimbursement criteria), obtain the patient&#39;s informed consent and set a date for the IPG placement. Pain relief is assessed by using the VAS scale22. 
	NOTE: The patient decides on the site of the IPG placement after the advantages and drawbacks of the different locations are discussed with the NMS.</li>
	<li>Perform antibiotic prophylaxis 30 minutes before incision using a single intravenous dose of Cefazolin 50 mg/kg, with a maximum of 2 g, with a 16 G needle.</li>
	<li>With the patient under general anesthesia (same protocol as mentioned in Step 4.3), make a 7 cm-long and 2 cm-deep incision and create a pocket for the IPG in the subcutaneous fat of the abdominal wall or the external quadrant of a buttock, according to patients&#39; wishes (as discussed before surgery - Step 6.1).</li>
	<li>Excise the dorsal scar made for the lead implantation (Step 4.3), dissect the lead extensions from the surrounding tissues, and disconnect the lead from its external extrinsic extensions.</li>
	<li>Tunnel the intrinsic extension of the lead towards the implantation site of the IPG.</li>
	<li>Connect the lead&#39;s intrinsic extensions to its IPG.</li>
	<li>Suture the subcutaneous layer by simple interrupted stitches of 2/0 and 1/0 braided synthetic absorbable suture material.</li>
	<li>Make a dermal subcuticular suture using finer absorbable 3/0 suture material and apply antiseptic and bandages. During this step, administer a single IV dose of Paracetamol 1 gm and Tradonal 100 mg.</li>
</ol>
7. Postoperative Care and Follow-up Visits
<ol>
	<li>With the clinician programmer, set the programming parameters according to the ones that worked the best during the trial period (Step 5.7).</li>
	<li>Teach the patient how to use the programmer25. Explain again the different components of the neurostimulation system. Educate the patient to avoid activities requiring excessive twisting or stretching.</li>
	<li>Instruct the patient always to inform any healthcare personnel that they have an implanted neurostimulation system before any procedure is begun. Provide instructions about the warnings (CT-scan, defibrillation and cardioversion, electrocautery, lithotripsy, MRI, microwave ablation, and security screening devices) and precautions (bone growth stimulators, dental drills and ultrasonic probes, electrolysis, electromagnetic field devices, laser procedures, psychotherapeutic procedures, radiation therapy, and household items) for a neurostimulation system.</li>
	<li>Ensure close follow-up of the patient after the surgery to check for surgical site infection and appropriate paresthesia coverage.</li>
</ol>

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The authors have nothing to disclose.

Recent studies have demonstrated that SCS can reliably improve the different pain components of FBSS patients, improve their quality of life (e.g., quality of sleep and physical activity), and these benefits are sustained during a long-term follow-up3,17,18,19.
Depending on the localization of the pain, we use a different approach. When the patient has only ...

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Before FBSS can be established, other conditions, such as persistent nerve root compression, permanent nerve root injury as a consequence of the original compression or surgery, arachnoiditis, incorrect initial diagnoses, and documented mechanical causes for low back pain (such as spinal instability, posterior joint osteoarthritis, spondylolysthesis, and discogenic pain), should be excluded1,2,3. FBSS patients may have severe or disabling neuropathic pain, and the syndrome is worrisome since it is chronic and resistant to conventional treatment. Its incidence and prevalence are similar to those of rheumatoid arthritis4. It is thus a great burden for industrialized societies5.
Spinal cord stimulation (SCS) with dorsal epidural leads can be used to treat back pain (BP) and leg pain (LP) in FBSS patients, although the SCS pain relief mechanism has not been fully investigated. According to the gate control theory, which was first proposed by Ronald Melzack and Patrick Wall in 1965, the brain monitors the activity of a tiny neural network distributed along the dorsal horn of the spinal cord that is regulated by nociceptive but also non-nociceptive afferents6. These complex circuits in the superficial dorsal horn of the spinal cord are responsible for relieving pain in a specific location in the body when an intense tactile stimulus is applied to the same place7,8. However, several studies have shown that SCS is not only dependent on this theory. Several neurotransmitters (acetylcholine, gamma-aminobutyric acid, and serotonin) have been reported to have a role in the SCS mechanism9,10,11,12, as well as numerous brain areas13,14 and different spinal fibers15.
An SCS device includes an epidural lead, internal pulse generator (IPG), and an extension cable to connect the lead to the IPG. The stimulation settings are adjusted by an external remote control. Two types of electrode can be used, namely, percutaneous and surgical leads.
The efficacy of SCS in improving the radicular LP component of FBSS has already been demonstrated in previously published studies, including the EVIDENCE study16, and two new technologies have recently been shown to be effective for treating the BP component, which is known to be recalcitrant to SCS. The first one is high-frequency stimulation17. The second one is the use of surgical multicolumn lead3,18. The main disadvantages of the former technique are that their batteries need more frequent charging and that the programming optimization is challenged by longer &#34;wash-in&#34; times19. The latter technique is more invasive than the percutaneous high-frequency stimulation technique because it requires a small laminectomy, making peroperative paresthesia mapping under local anesthesia challenging, although possible3. Indeed, this procedure can be performed under local anesthesia supplemented by conscious sedation or spinal anesthesia3. In our institution, when targeting back pain in FBSS patients, we place such surgical leads through a small laminectomy at the 10th thoracic level with the patient under general anesthesia. The lasting efficacy of this method with such multicolumn leads for treating LP and BP in FBSS patients has been demonstrated by 3 year follow-up18. A detailed protocol of our method is given below.

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treating low back pain in failed back surgery patients with multicolumn-lead spinal cord stimulation

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be used to treat back and leg pain in FBSS patients. This paper presents a detailed protocol for using spinal cord stimulation with surgical leads in FBSS patients. In our department, with the patient under general anesthesia, we place the lead in the epidural space by means of a small laminectomy at the 10th thoracic level. Placement of the lead is followed by a 1 month trial period with an externalized lead. If pain relief is greater than 50% at the end of this 1 month stimulation trial (required by Belgian reimbursement criteria), an internal pulse generator is then placed under the skin and connected to the lead in a second surgical procedure. We have demonstrated that using this technique in rigorously selected FBSS patients can significantly improve back pain, leg pain, patient activity, and quality of life for a sustained period of time.

A prospective, non-randomized, controlled study of 62 consecutive FBSS patients who were implanted with a multicolumn lead using this method in our center, CHR Citadelle, in Li&#232;ge, Belgium, was recently published in Neuromodulation18 . All patients had had previous spinal surgery, had been screened for possible secondary causes of their pain, and were refractory to optimal medical therapy. Multicolumn surgical leads were placed in all 62 patients in the projec...

Watch this Scientific Journal Video about Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation at JoVE.com

Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Failed back surgery syndrome (FBSS) refers to persistent, chronic pain following spinal surgery. Spinal cord stimulation with dorsal epidural leads can be ...

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14.4K Views.  CHR Citadelle. This paper presents a method that uses spinal cord stimulation with a multicolumn lead to treat neuropathic low back pain in failed back surgery patients.

Video: Treating Low Back Pain in Failed Back Surgery Patients with Multicolumn-lead Spinal Cord Stimulation

Functional Magnetic Resonance Imaging (fMRI) with Auditory Stimulation in Songbirds

The neurobiology of birdsong, as a model for human speech, is a pronounced area of research in behavioral neuroscience. Whereas electrophysiology and molecular approaches allow the investigation of either different stimuli on few neurons, or one stimulus in large parts of the brain, blood oxygenation level dependent (BOLD) functional Magnetic Resonance Imaging (fMRI) allows combining both advantages, i.e. compare the neural activation induced by different stimuli in the entire brain at once. fMRI in songbirds is challenging because of the small size of their brains and because their bones and especially their skull comprise numerous air cavities, inducing important susceptibility artifacts. Gradient-echo (GE) BOLD fMRI has been successfully applied to songbirds 1-5 (for a review, see 6). These studies focused on the primary and secondary auditory brain areas, which are regions free of susceptibility artifacts. However, because processes of interest may occur beyond these regions, whole brain BOLD fMRI is required using an MRI sequence less susceptible to these artifacts. This can be achieved by using spin-echo (SE) BOLD fMRI 7,8 . In this article, we describe how to use this technique in zebra finches (Taeniopygia guttata), which are small songbirds with a bodyweight of 15-25 g extensively studied in behavioral neurosciences of birdsong. The main topic of fMRI studies on songbirds is song perception and song learning. The auditory nature of the stimuli combined with the weak BOLD sensitivity of SE (compared to GE) based fMRI sequences makes the implementation of this technique very challenging.

Functional Magnetic Resonance Imaging fMRI with Auditory Stimulation in Songbirds

This article shows an optimized procedure for imaging of the neural substrates of auditory stimulation in the songbird brain using functional Magnetic Resonance Imaging (fMRI). It describes the preparation of the sound stimuli, the positioning of the subject and the acquisition and subsequent analysis of the fMRI data.

The neurobiology of birdsong, as a model for human speech, is a pronounced area of research in behavioral neuroscience. Whereas electrophysiology and ...

Use of the Operant Orofacial Pain Assessment Device (OPAD) to Measure Changes in Nociceptive Behavior

We present an operant system for the detection of pain in awake, conscious rodents. The Orofacial Pain Assessment Device (OPAD) assesses pain behaviors in a more clinically relevant way by not relying on reflex-based measures of nociception. Food fasted, hairless (or shaved) rodents are placed into a Plexiglas chamber which has two Peltier-based thermodes that can be programmed to any temperature between 7 &deg;C and 60 &deg;C. The rodent is trained to make contact with these in order to access a reward bottle. During a session, a number of behavioral pain outcomes are automatically recorded and saved. These measures include the number of reward bottle activations (licks) and facial contact stimuli (face contacts), but custom measures like the lick/face ratio (total number of licks per session/total number of contacts) can also be created. The stimulus temperature can be set to a single temperature or multiple temperatures within a session. The OPAD is a high-throughput, easy to use operant assay which will lead to better translation of pain research in the future as it includes cortical input instead of relying on spinal reflex-based nociceptive assays.

Use of the Operant Orofacial Pain Assessment Device OPAD to Measure Changes in Nociceptive Behavior

We present a user-friendly, high-throughput operant system for the evaluation of pain behaviors in awake, conscious rodents. The Orofacial Pain Assessment Device (OPAD) can assess pain through a reward/conflict paradigm thus providing a more humane way of testing. This protocol will yield more clinically relevant and translational data from rodents.

We present an operant  system for the detection of pain in awake, conscious rodents. The Orofacial  Pain Assessment Device (OPAD) assesses pain behaviors ...

Stimulating the Lip Motor Cortex with Transcranial Magnetic Stimulation

Transcranial magnetic stimulation (TMS) has proven to be a useful tool in investigating the role of the articulatory motor cortex in speech perception. Researchers have used single-pulse and repetitive TMS to stimulate the lip representation in the motor cortex. The excitability of the lip motor representation can be investigated by applying single TMS pulses over this cortical area and recording TMS-induced motor evoked potentials (MEPs) via electrodes attached to the lip muscles (electromyography; EMG). Larger MEPs reflect increased cortical excitability. Studies have shown that excitability increases during listening to speech as well as during&#160;viewing speech-related movements. TMS can be used also to disrupt the lip motor representation. A 15-min train of low-frequency sub-threshold repetitive stimulation has been shown to suppress motor excitability for a further 15-20 min. This TMS-induced disruption of the motor lip representation impairs subsequent performance in demanding speech perception tasks and modulates auditory-cortex responses to speech sounds. These findings are consistent with the suggestion that the motor cortex contributes to speech perception. This article describes how to localize the lip representation in the motor cortex and how to define the appropriate stimulation intensity for carrying out both single-pulse and repetitive TMS experiments.

Transcranial magnetic stimulation (TMS) has proven to be a useful tool in investigating the role of the articulatory motor cortex in speech perception.&#160; This article describes how to record motor evoked potentials (MEPs) from the lip muscles and how to disrupt the motor lip representation using repetitive TMS.

Transcranial magnetic stimulation (TMS) has proven to be a useful tool in investigating the role of the articulatory motor cortex in speech perception. ...

Treating Clinical Depression with Repetitive Deep Transcranial Magnetic Stimulation Using the Brainsway H1-coil

Repetitive transcranial magnetic stimulation (rTMS) is an emerging non-pharmacological approach to treating many brain-based disorders. rTMS uses electromagnetic coils to stimulate areas of the brain non-invasively. Deep transcranial magnetic stimulation (dTMS) with the Brainsway H1-coil system specifically is a type of rTMS indicated for treating patients with major depressive disorder (MDD) who are resistant to medication. The unique H1-coil design of this device is able to stimulate neuronal pathways that lie deeper in the targeted brain areas than those reached by conventional rTMS coils. dTMS is considered to be low-risk and well tolerated, making it a viable treatment option for people who have not responded to medication or psychotherapy trials for their depression.
Randomized, sham-control studies have demonstrated that dTMS produces significantly greater improvement in depressive symptoms than sham dTMS treatment in patients with major depression that has not responded to antidepressant medication. In this paper, we will review the methodology for treating major depression with dTMS using an H1-coil.

Here we present a protocol outlining the methodology for treatment of Major Depressive Disorder using the deep Transcranial Magnetic Stimulation (dTMS) system.

Repetitive transcranial magnetic stimulation (rTMS) is an emerging non-pharmacological approach to treating many brain-based disorders. rTMS uses ...

Eye-Tracking Control to Assess Cognitive Functions in Patients with Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with pathological involvement of upper and lower motoneurons, subsequently leading to progressive loss of motor and speech abilities. In addition, cognitive functions are impaired in a subset of patients. To evaluate these potential deficits in severely physically impaired ALS patients, eye-tracking is a promising means to conduct cognitive tests. The present article focuses on how eye movements, an indirect means of communication for physically disabled patients, can be utilized to allow for detailed neuropsychological assessment. The requirements, in terms of oculomotor parameters that have to be met for sufficient eye-tracking in ALS patients are presented. The properties of stimuli, including type of neuropsychological tests and style of presentation, best suited to successfully assess cognitive functioning, are also described. Furthermore, recommendations regarding procedural requirements are provided. Overall, this methodology provides a reliable, easy to administer and fast approach for assessing cognitive deficits in patients who are unable to speak or write such as patients with severe ALS. The only confounding factor might be deficits in voluntary eye movement control in a subset of ALS patients.

Cognitive deficits are common in about one third of patients with amyotrophic lateral sclerosis, a neurological condition leading to progressive impairments in speech and movement abilities. To conduct cognitive tests in patients unable to speak or write a reliable and easy to administer eye-tracking paradigm was developed.

Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with pathological involvement of upper and lower motoneurons, subsequently leading to ...

Using Laser Doppler Imaging and Monitoring to Analyze Spinal Cord Microcirculation in Rat

Laser Doppler flowmetry (LDF) is a noninvasive method for blood flow (BF) measurement, which makes it preferable for measuring microcirculatory alterations of the spinal cord. In this article, our goal was to use both Laser Doppler imaging and monitoring to analyze the change of BF after spinal cord injury. Both the laser Doppler image scanner and the probe/monitor were being employed to obtain each readout. The data of LDPI provided a local distribution of BF, which gave an overview of perfusion around the injury site and made it accessible for comparative analysis of BF among different locations. By intensely measuring the probing area over a period of time, a combined probe was used to simultaneously measure the BF and oxygen saturation of the spinal cord, showing overall spinal cord perfusion and oxygen supply. LDF itself has a few limitations, such as relative flux, sensitivity to movement, and biological zero signal. However, the technology has been applied in clinical and experimental study due to its simple setup and rapid measurement of BF.

Here we present a combination of laser Doppler perfusion imaging (LDPI) and laser Doppler perfusion monitoring (LDPM) to measure spinal cord local blood flows and oxygen saturation (SO2), as well as a standardized procedure for introducing spinal cord trauma on rat.

Laser Doppler flowmetry (LDF) is a noninvasive method for blood flow (BF) measurement, which makes it preferable for measuring microcirculatory ...

Paradigms of Lower Extremity Electrical Stimulation Training After Spinal Cord Injury

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with numerous cardiometabolic health consequences. These changes are likely to increase the risk of developing chronic secondary conditions and impact the quality of life in persons with SCI. Surface neuromuscular electrical stimulation evoked resistance training (NMES-RT) was developed as a strategy to attenuate the process of skeletal muscle atrophy, decrease ectopic adiposity, improve insulin sensitivity and enhance mitochondrial capacity. However, NMES-RT is limited to only a single muscle group. Involving multiple muscle groups of the lower extremities may maximize the health benefits of training. Functional electrical stimulation-lower extremity cycling (FES-LEC) allows for the activation of 6 muscle groups, which is likely to evoke greater metabolic and cardiovascular adaptation. Appropriate knowledge of the stimulation parameters is key to maximizing the outcomes of electrical stimulation training in persons with SCI. Adopting strategies for long-term use of NMES-RT and FES-LEC during rehabilitation may maintain the integrity of the musculoskeletal system, a pre-requisite for clinical trials aiming to restore walking after injury. The current manuscript presents a combined protocol using NMES-RT prior to FES-LEC. We hypothesize that muscles conditioned for 12 weeks prior to cycling will be capable of generating greater power, cycle against higher resistance and result in greater adaptation in persons with SCI.

Spinal cord injury is a traumatic medical condition that may result in elevated risks of chronic secondary metabolic disorders. Here, we presented a protocol using surface neuromuscular electrical stimulation-resistance training in conjunction with functional electrical stimulation-lower extremities cycling as a strategy to ameliorate several of these medical problems.

Skeletal muscle atrophy, increased adiposity and reduced physical activity are key changes observed after spinal cord injury (SCI) and are associated with ...

Brain State-dependent Brain Stimulation with Real-time Electroencephalography-Triggered Transcranial Magnetic Stimulation

The effect of a stimulus to the brain depends not only on the parameters of the stimulus but also on the dynamics of brain activity at the time of the stimulation. The combination of electroencephalography (EEG) and transcranial magnetic stimulation (TMS) in a real-time brain state-dependent stimulation system allows the study of relations of dynamics of brain activity, cortical excitability, and plasticity induction. Here, we demonstrate a newly developed method to synchronize the timing of brain stimulation with the phase of ongoing EEG oscillations using a real-time data analysis system. This real-time EEG-triggered TMS of the human motor cortex, when TMS is synchronized with the surface EEG negative peak of the sensorimotor &#181;-alpha (8-14 Hz) rhythm, has shown differential corticospinal excitability and plasticity effects. The utilization of this method suggests that real-time information about the instantaneous brain state can be used for efficacious plasticity induction. Additionally, this approach enables personalized EEG-synchronized brain stimulation which may lead to the development of more effective therapeutic brain stimulation protocols.

This paper describes real-time electroencephalography-triggered transcranial magnetic stimulation to study and modulate human brain networks.

The effect of a stimulus to the brain depends not only on the parameters of the stimulus but also on the dynamics of brain activity at the time of the ...

Home-Based Prescribed Pulmonary Exercise in Patients with Stable Chronic Obstructive Pulmonary Disease

As a systemic disease, chronic obstructive pulmonary disease (COPD) affects the respiratory system, inducing restless and exercise dyspnea. It also impacts exercise capacity and forms a vicious circle in which it further aggravates the condition of patients and accelerates disease progression. As a functional holistic exercise, traditional Chinese exercises (TCE) play an important role in the rehabilitation of COPD on the basis of adjusting the breath and performing coordinated movements. This study investigates the effects of prescribed pulmonary exercises (which are modified from TCE) on exercise capacity of upper and lower limbs, endurance exercise capacity, and quality of life in stable COPD patients. The goal is to determine the accessibility of these prescribed exercises in COPD rehabilitation. Participants are randomly divided into a non-exercise control group (CG) or prescribed pulmonary exercise group (PG) at a ratio of 1: 1. The PG receives intervention for 60 min twice per day, 7 days a week, for a total of 3 months. The intensity is measured using the Borg category-ratio 10 scale and with a heart-rate monitor. Then, an exercise capacity test and quality of life questionnaire are scheduled at 1 week before and after the formal intervention. After 3 months of intervention, the 30 s arm curl test, 30 s sit-to-stand test, 6 min walking test, and quality of life show significant improvement in COPD patients (p &#60; 0.05). These findings indicate that prescribed pulmonary exercises can be applied as alternative, convenient, and effective home- and community-based exercises for stable COPD patients.

Presented here is a protocol to investigate the effects of home-based prescribed pulmonary exercise in stable chronic obstructive pulmonary disease (COPD) patients, which is modified based on traditional Chinese exercises according to dyspnea and limited exercise capacity observed in COPD patients.

As a systemic disease, chronic obstructive pulmonary disease (COPD) affects the respiratory system, inducing restless and exercise dyspnea. It also ...

Using Unidirectional Rotations to Improve Vestibular System Asymmetry in Patients with Vestibular Dysfunction

The vestibular system provides information about head movement and mediates reflexes that contribute to balance control and gaze stabilization during daily activities. Vestibular sensors are located in the inner ear on both sides of the head and project to the vestibular nuclei in the brainstem. Vestibular dysfunction is often due to an asymmetry between input from the two sides. This results in asymmetrical neural inputs from the two ears, which can produce an illusion of rotation, manifested as vertigo. The vestibular system has an impressive capacity for compensation, which serves to rebalance how asymmetrical information from the sensory end organs on both sides is processed at the central level. To promote compensation, various rehabilitation programs are used in the clinic; however, they primarily use exercises that improve multisensory integration. Recently, visual-vestibular training has also been used to improve the vestibulo-ocular reflex (VOR) in animals with compensated unilateral lesions. Here, a new method is introduced for rebalancing the vestibular activity on both sides in human subjects. This method consists of five unidirectional rotations in the dark (peak velocity of 320&#176;/s) toward the weaker side. The efficacy of this method was shown in a sequential, double-blinded clinical trial in 16 patients with VOR asymmetry (measured by the directional preponderance in response to sinusoidal rotations). In most cases, VOR asymmetry decreased after a single session, reached normal values within the first two sessions in one week, and the effects lasted up to 6 weeks. The rebalancing effect is due to both an increase in VOR response from the weaker side and a decrease in response from the stronger side. The findings suggest that unidirectional rotation can be used as a supervised rehabilitation method to reduce VOR asymmetry in patients with longstanding vestibular dysfunction.

A new rehabilitation method is presented for rebalancing the vestibular system in patients with asymmetric responses, which consists of unidirectional rotations toward the weaker side. By directly modifying the vestibular pathway rather than enhancing the multisensory aspects of compensation, asymmetry can be normalized within 1-2 sessions and show lasting effects.

The vestibular system provides information about head movement and mediates reflexes that contribute to balance control and gaze stabilization during ...