This study was funded by the Christian Doppler Research Foundation of the Austrian Council for Research and Technology Development and the Austrian Federal Ministry of Science, Research and Economy. We thank Petra Gettinger for her assistance in the preparation of filming and Aron Cserveny for the preparation of the illustrations included in the manuscript and the rehabilitation leaflet. Frontiers in Neuroscience granted permission for reproducing the data presented in the original paper.

The study was approved by the local research ethics committee (number: 1009/2014) and carried out in accordance with the Declaration of Helsinki. All patients provided written informed consent to participate in this study.
1. Patient Education
<ol>
	<li>Despite any given previous information to the patient, use the first post-surgical consultation/therapy session to thoroughly explain the type of injury, as well as&#160;the performed surgery in detail.
	<ol>
		<li>Visualize the nerve transfers, that were performed, on a scheme or print-out from an anatomy figure.</li>
		<li>Explain how the altered neural pathway initially requires thinking of a nerve&#8217;s original movement pattern.</li>
	</ol>
	</li>
	<li>Give the patient a rough rehabilitation plan and an idea of what outcomes might be realistic at what point in time.</li>
	<li>If the patient suffers from the negative consequences of the injury on a psychological level16,17 or needs support in coping with stress or pain, contact a psychologist.</li>
	<li>Ask the patient to explain the impact of the nerve transfers in their own words to find out how they understood the concept.
	<ol>
		<li>If necessary, repeat certain explanations and answer open questions.</li>
		<li>If the rehabilitation institution has a leaflet with the most important facts, hand this over to the patient (see Supplementary File for an example).</li>
	</ol>
	</li>
	<li>Discuss a home program with the patient.
	<ol>
		<li>Explain that a high frequency of training is important for good outcomes, and thus home exercises are an integral part of rehabilitation.</li>
		<li>Discuss with the patient how he/she thinks this can be best approached. Thus, empower the patient to assume responsibility for his/her own rehabilitation.</li>
		<li>Hand out the discussed home exercise program in a written form. Make sure it only contains exercises that were previously performed within a therapy session.</li>
		<li>In order to preserve adherence over time, regularly ask the patient how he/she feels about the home program and discuss how it should be altered to be feasible and meaningful to the patient.</li>
	</ol>
	</li>
</ol>
2. Enhancing Cortical Re-presentation of the Denervated Body Part
NOTE: The following rehabilitation techniques promote activation of the denervated motor and sensory cortical areas to regain cortical representation of the paralyzed body part. During this phase no active muscle contraction is possible.
<ol>
	<li>Follow an approach for lateralization training (left/right discrimination) as described by Mosely et al.18.
	<ol>
		<li>Prepare cards showing left and right extremities in a random order (upper extremity, if the upper extremity is affected and lower extremity for lower extremity nerve injuries). Show them to the patient in a random order.</li>
		<li>Ask the patient if a left or a right extremity is shown. While speed of approximately 2 s/card is normal18, give the patient at least 15 s to answer, if needed.</li>
		<li>Give the patient feedback, and if necessary, time to understand why the answer was wrong.</li>
		<li>Do this for 5 to 10 min to avoid fatigue. Ask the patient to do this at home as well, twice a day for 5-10 min.</li>
	</ol>
	</li>
	<li>Instruct the patient to imagine movements of the paralyzed body part, although no motor output is expected.
	<ol>
		<li>Make sure that the patient is in a calm environment without any distraction.</li>
		<li>Ask the patient which movements of the paralyzed extremity are easy to imagine.</li>
		<li>Instruct the patient to imagine these movements for about 5 min with the exact timing depending on the patient&#8217;s ability to fully concentrate on these imagined movements.</li>
		<li>Within the treatment process, instruct the patient to imagine more complex motions as well.</li>
		<li>As a home exercise, ask the patient to imagine these movements 5 to 10 min, twice a day.</li>
	</ol>
	</li>
	<li>Use the mirror therapy to create the illusion of active movement of the paralyzed part19,20.
	<ol>
		<li>Place a standing mirror or a mirror box in front of the therapist and the patient. Place it on a desk for the upper extremity or on the floor for the lower extremity.</li>
		<li>Explain that mirror therapy works by making use of the reflection of the sound side to create the image of the simultaneous movement of the sound side and denervated extremity19,21. Shortly demonstrate this with the therapist&#8217;s own upper or lower extremity.</li>
		<li>Place the mirror medially in front of the patient in a way that he/she sees the reflection of the sound side exactly where the injured extremity is expected. Make sure that the whole injured extremity is covered by the mirror (box), i.e., it cannot be seen by the patient.</li>
		<li>Ask him/her which movements he/she can easily imagine. Instruct the patient to perform these movements with the sound side while looking at the mirror. Start with slow movements.</li>
		<li>Instruct the patient to move both sides for 5 to 10 min. Explain, that the injured side will not move, but that it is still important to generate the illusion of simultaneous movement of both sides.</li>
		<li>Within the treatment process, encourage the patient to also perform movements that he/she cannot imagine easily to gradually increase the difficulty.</li>
		<li>As a home exercise, ask the patient to perform/imagine these movements 5 to 10 min, twice a day. 
		NOTE: Together with the other exercises to enhance cortical reorganization, this accounts for about 20 min of the home program, twice a day. Ask the patient if this is feasible. Otherwise, choose one or two of these interventions based on the patient&#8217;s preferences and reduce the training time to a manageable amount.</li>
	</ol>
	</li>
	<li>As there is no active motion expected within the first months after surgery, make sure that the range of motion (ROM) is preserved in all joints.
	<ol>
		<li>Let the patient actively move all joints.</li>
		<li>Instruct the patient to perform this every day by him/herself.</li>
		<li>Additionally, in paralyzed hands or ankles use splints or orthoses to stabilize the joints in a position that avoids contractures of joints, ligaments, and tendons (as the intrinsic plus position for the hand22). If necessary, fabricate a hand splint or make sure that the patients get a well-fitted device. In patients with an unstable shoulder and/or no elbow flexion use a sling15.</li>
		<li>Depending on the patient&#8217;s needs, include exercises for body symmetry, trunk stability, and posture. Especially, if hand function is severely impaired, include training of one-handed activities and provide the patient with assistive devices.</li>
	</ol>
	</li>
</ol>
3. Motor Activation Using a Donor Side Approach
<ol>
	<li>Start this part of the rehabilitation as soon as the first volitional contraction of the re-innervated muscle can be detected, which can usually be expected within 3-5 months after surgery (see Table 2).
	<ol>
		<li>Set up a system for surface EMG biofeedback by unpacking it on a table, plugging in all cables and pressing the power button. This can be a stand-alone device, or one connected to a computer. If a computer is used, connect the device with the computer and start the appropriate software.</li>
		<li>Prepare the patient&#8217;s skin to reduce impedance23. Do so by carefully shaving the respective body part and/or by gently removing dead skin cells with a peeling gel and/or a wet paper towel. Shortly explain the functionality of the system to the patient.</li>
		<li>Ask the patient to think of movements that the donor nerves were originally responsible for (e.g., hand closing if the ulnar nerve was used) and palpate the recipient muscle.</li>
		<li>Place a surface EMG electrode on the exact position, where muscle contraction can be palpated. While surface EMG may be detected with wet and dry electrodes, in this experiment dry electrodes are preferred for testing as these can be easily moved on the skin to alter electrode position. Even if no movement can be palpated, check for the EMG activity regularly within the first 3-6 months after surgery. 
		NOTE: The re-innervation can be confirmed, if the signal amplitude during activation is repeatedly 2-3 times higher than background noise during relaxation8.</li>
		<li>If this cannot be confirmed, slightly change the position of the electrode and try other motor commands related to the donor nerve (e.g., ulnar abduction or flexion of the wrist, if the ulnar nerve was used as a donor). Otherwise, continue with the interventions for cortical activation and test again after a few weeks.</li>
	</ol>
	</li>
	<li>Train the activation of the newly re-innervated muscles with sEMG biofeedback.
	<ol>
		<li>As the first step of muscle activation training, educate the patient on the function of sEMG biofeedback and explain the principles of the donor activation approach.</li>
		<li>Switch on the biofeedback system and place the surface EMG electrode on the patient&#8217;s skin above the muscle to display the patient&#8217;s muscle activation.</li>
		<li>Make sure that the patient is comfortably seated and instruct the patient to think of movement patterns related to the donor nerve while picking up sEMG signals from the recipient muscle. If a system with the possibility to adjust signal gains is used, set it up in a way that the signal amplitude is high enough to be easily observed. In the beginning, this usually requires a high amplification.</li>
		<li>As soon as the patient can repeatably activate the muscle, ask him/her to fully relax after muscle activation, which corresponds to EMG amplitudes close to zero. Full relaxation is often hard to achieve for the patient and can take some time. Ask the patient to repeatedly activate the muscle and fully relax it.</li>
		<li>Try different movement cues and electrode positions in order to find the highest amplitude. After finding a good combination, maintain it the rest of the session.</li>
		<li>Provide the patient with a structured home exercise program including the amount of training per week (10-20 min of concentrated training per day is recommended) and exact instructions of what to train. If it is possible for the patient to use a device for sEMG biofeedback at home, encourage this8. Update the home exercise program regularly.</li>
		<li>As soon as the patient feels confident with the sEMG setup, introduce motor commands including both the activation of the donor nerve and the actual function of the recipient muscle. For a patient with an Oberlin&#8217;s ulnar nerve transfer to the biceps muscle, this means thinking of hand closing and elbow flexion at the same time. 
		CAUTION: In patients where a nerve branch from an antagonistic muscle was transferred, do only focus on the donor nerve function and omit this step.</li>
		<li>Train muscle activation with and without sEMG biofeedback until muscle strength is sufficient to overcome gravity or resistance of antagonistic muscles. Additionally, repeat the interventions for activation of the motor cortex.</li>
	</ol>
	</li>
</ol>
4. Re-learning the Original Movement Pattern
<ol>
	<li>As soon as the muscle is strong enough to overcome gravity or the resistance of antagonistic muscles and joint stiffness, focus therapy on re-learning the original movement pattern of the recipient nerve. This means that a patient after an Oberlin&#8217;s ulnar nerve transfer finally needs to learn how to flex the elbow without any movement of the hand and conversely, move the hand without flexion of the elbow.</li>
	<li>Encourage the patient to slightly activate the recipient muscle without the movement in the muscles originally innervated by the donor nerve.</li>
	<li>Support this by using sEMG biofeedback with two channels. Place one bipolar electrode on the skin above the re-innervated muscle and put the other one on the skin above the original donor nerve muscle. This allows the patient to simultaneously see the activation of both muscles. Encourage the patient to activate the recipient muscle and ensure that the donor muscle is relaxed with a low EMG signal amplitude.
	<ol>
		<li>Let the patient know that signal separation is usually easier with slight muscle activation and that unwanted co-contraction of both muscles is common at the beginning of training.</li>
		<li>Using the same sEMG setup, ask the patient to activate the donor muscle without the activation of the re-innervated muscle and monitor for desirable/undesirable strategies resulting in better/worse separation of signals. Encourage strategies that support signal separation.</li>
		<li>If both signals can be separated with slight muscle contractions, ask the patient to perform stronger contractions.</li>
	</ol>
	</li>
	<li>As soon as good signal separation while using sEMG biofeedback can be observed, ask the patient to perform separated &#8220;donor&#8221; and &#8220;recipient&#8221; movements without feedback.</li>
	<li>As this phase is cognitively demanding and repetition is of great importance for motor re-learning, make sure that the patient has a suitable home exercise program. Again, encourage the use of sEMG biofeedback devices at home, if possible.</li>
	<li>With increased motor function, encourage the patient to do more complex tasks including increased muscle force or improved precision. Also start &#8220;classic&#8221; strengthening exercises, if necessary.</li>
	<li>Finally, focus on activities of daily living and those needed in the patient&#8217;s home, work environment and when performing sports.</li>
	<li>In lower limb nerve transfers, start gait training with the focus on avoiding undesired compensatory movements.
	<ol>
		<li>Ask the patient to walk along a corridor and analyze the gait based on the principles of observational gait analysis24,25.</li>
		<li>Define deviations from the physiological gait pattern and analyze them with respect to the origin (e.g., which muscle might be weak) and the connection between each other (e.g., how hip kinematics affects knee kinematics and vice versa). If necessary, for clarification, conduct additional tests (e.g., for muscle strength or joint mobility).</li>
		<li>Develop a treatment plan based on your findings24,25.</li>
		<li>Evaluate the interventions while the patient is doing them, as well as the therapy progress over time. If necessary, conduct another gait analysis and/or change interventions.</li>
	</ol>
	</li>
	<li>See the patient three, six and twelve months after discharge from rehabilitation to find out about the long-term therapy success and patient satisfaction. If necessary and requested by the patient provide further training sessions.</li>
	<li>Evaluate, if the functional goal, that was discussed with the patient before surgery/at the beginning of rehabilitation could be reached. 
	NOTE: For some patients, this might be fully functional recovery, while for others the return of minimal function might be sufficient.
	<ol>
		<li>Ask the patient, if he/she is satisfied with the rehabilitation outcome and make clear that this is very subjective and is not necessarily reflected by any scores in outcome assessment instruments.</li>
		<li>If the patient is unsatisfied with the outcome, inform the patient about further (surgical) strategies to enhance function, as well as the possibility of using functional orthoses to compensate limited muscle strength.</li>
	</ol>
	</li>
</ol>

The authors have nothing to disclose.

Recently, nerve transfers have been increasingly used to restore function after severe proximal nerve injuries with promising outcomes1,4,31,32. However, while there is a consensus that structured training programs are necessary to promote beneficial neuroplastic changes33,34,35, there is no structured protocol available to describe motor rehabilitation approaches after nerve transfers step-by-step. Therefore, the aim of the presented protocol was to provide detailed instructions for post-surgical rehabilitation to embrace cortical changes and enhance surgical outcomes. In contrast to other protocols9,36, visualization of muscular activity via surface EMG biofeedback is a key element in the presented protocol.
Within therapy, patient education is a critical step as the patient needs to understand the rather complex surgical procedure and be educated on activities improving the health status in order to be actively involved in the long rehabilitation process8,13,37. There is broad agreement that repetition is fundamental and daily home exercises are needed to reinforce a well-established cortical representation of the hand8,34,38,39. Apart from pure patient information, the authors strongly recommend a patient-centered approach for rehabilitation. This additionally involves treating the patient as a unique person, the involvement of the patient in care, good clinician-patient communication and empowering the patient. In medical rehabilitation, this approach positively influences patient satisfaction and outcomes40. Regarding the motor rehabilitation itself, it is recommended to start interventions before re-innervation of the muscles and to follow a donor activation focused approach9. To ensure that muscular activity is detected as early as possible, EMG biofeedback devices can be used. While the authors are aware that EMG biofeedback devices are not yet clinical standard, their use is highly recommended as they allow to start early active motor rehabilitation and provide valuable feedback on newly re-innervated muscles8.
The principles described within this protocol can be applied for different types of nerve transfers, although modifications within the protocol might be necessary. While motor re-learning is relatively easy if synergistic muscles/nerves were used, the use of antagonistic muscles/nerves requires a longer rehabilitation time and the use of biofeedback might be of even greater importance3,8. Especially in those cases where a higher amount of repetitions is needed, future protocols might also include serious games to maintain patient motivation41.
As the timing of nerve regeneration and the amount of recovery hugely depends on the injury and surgical interventions, there is no strict timeline for rehabilitation. Instead, the therapist is asked to proceed depending on the signs of motor recovery as stated in the protocol. In the same way, it is important to note that the success of nerve transfer surgery is based on many factors including type and severity of the injury, the surgeon&#8217;s skills, and expertise as well as the patient&#8217;s age, health status, cognition and motivation8,13,42,43. While rehabilitation is a main pillar for regaining function after severe nerve injuries, even the best program for motor re-education cannot improve function, if there are inadequate peripheral nerve regeneration and muscle re-innervation. Thus, the authors strongly recommend seeing the patients regularly together within a multidisciplinary team to be able to discuss if recovery goes as expected or if any additional medical interventions are necessary. However, especially after severe injuries such as C8 and Th1 nerve root avulsions, realistic outcomes might not include full recovery of extremity function3,30. In these cases, the clinical team needs to communicate this to the patient as soon as a realistic prognosis can be stated (approximately one year after the nerve transfers). At this point, further possibilities in rehabilitation, assistive devices or surgical interventions (as tendon transfers) need to be discussed. In cases, where absolutely no hand function returns, replacing the functionless limb with a prosthetic device can be considered as an option as well44,45. This is, however, only recommended as a last resort and after in-depth physical and psychological assessment46.
While the focus of peripheral nerve surgery usually lies on the reconstruction of motor function, sensory nerve transfers are sometimes used to restore the sensation in the hand after severe median or ulnar nerve injury4,47. Similar to motor nerve transfers, this creates altered sensory neural pathways and results in sensations that are felt as if they were originating from the previous innervation area of the donor nerve. Even if no sensory nerve transfers were performed, there can still be changed/reduced sensation either due to the injury itself27 or due to donor-side morbidity48. In these cases, timely re-education can help to improve the sensory function49, and reduce unwanted hyper-sensitivity and pain that often occurs after such injuries. To ensure good motor and sensory function, the authors strongly recommend complementing motor re-education with tailored therapy approaches to promote re-organization in the corresponding sensory cortex as well39,50,51. Regarding sensory re-education, it is recommended to start interventions before re-innervation of the skin49,52,53. This can include substitution of sensation by other senses as vision53 or auditory feedback54, as well as making use of the overlap of sensory innervation areas27,52. As soon as the patient has regained a certain amount of sensitivity, tactile gnosis and object recognition can be trained, while maintaining a high amount of sensory input34. Typical materials that can be used for this, include self-made plates with different surfaces to be recognized with closed eyes (see Figure 2) or a box filled with beans/lentils/rice (see Figure 3).
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/59840/59840fig2.jpg" /> 
Figure 2: Different surfaces can be used to support regaining of sensibility. Usually, the patient is asked to touch these with both hands first, while he/she might try afterwards&#160;to recognize the different surfaces without vision using only the hand with limited sensibility. <a href="https://www.jove.com/files/ftp_upload/59840/59840fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/59840/59840fig3.jpg" /> 
Figure 3: A box filled with rice for sensory re-education of the hand. In therapy, the patient might put his/her hand with reduced sensitivity carefully in this box and slowly move the hand. To focus the patient&#8217;s attention, the therapist can put some small objects (e.g., wooden blocks or paper clips) in this box and ask to find them without visual control. <a href="https://www.jove.com/files/ftp_upload/59840/59840fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
However, in both sensory and motor re-education, there is only limited evidence regarding the choice of interventions needed to promote good recovery34. This limits the validity of the proposed rehabilitation protocol, as for other protocols. While the described protocol was assessed within a feasibility study and motor outcomes were similar or slightly better than those reported in the literature8, this study was performed on a small sample size and without a control group. This makes it impossible to compare the outcomes, advantages, and disadvantages of this protocol with respect to previous ones. Further research needs to include controlled studies in order to compare the possible advantages of using surface EMG biofeedback to conventional approaches.

Selective nerve transfers provide an opportunity for restoring the motor function after nerve injuries when recovery by the use of neurolysis, nerve repair, or nerve grafting cannot be expected1,2. Possible indications for nerve transfers are severe distal nerve injuries, avulsion-type injuries, the lack of available nerve roots for grafting, the extensive scarring at the injury site and delayed reconstruction3,4. Following motor nerve injury, reconstruction is time-critical as degeneration of muscle tissue and motor end plates only allow for the successful muscle re-innervation within 1-2 years after injury5,6. Here, nerve transfers provide the advantage of a relatively short re-innervation time after surgery, as they allow nerve coaptation close to the target. This procedure, also known as neurotization, involves the surgical redirection of an intact nerve (donor nerve) to the distal part of the recipient nerve. As this connection is distal to the damaged site of the recipient nerve, it allows bypassing the injured nerve segment7.
As neural pathways are altered after nerve transfer surgery, patients cannot be treated with standard post-operative therapy protocols otherwise used after direct nerve repair8,9. While donor axons grow into the new target, they take over a function they did not have before while cortically still being connected to their original function. As an example, the Oberlin ulnar nerve transfer is used to restore elbow flexion after irreparable damage to the upper trunk or nerve roots C5 and C61. As shown in Figure 1, it involves transferring one or more ulnar nerve fascicles to the musculocutaneous motor branch of the biceps muscle10. However, after the successful re-innervation, these fascicles of the ulnar nerve are cortically still connected to their previous function of finger flexion and/or ulnar abduction and flexion of the wrist. On a functional level this implies that at the beginning of the rehabilitation, the patient needs to focus on the previous nerve function (hand closing) in order to activate and strengthen the recipient muscle (biceps contraction). This approach is also known as &#8220;donor activation focused rehabilitation approach&#8221;9.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/59840/59840fig1.jpg" /> 
Figure 1: Schematic illustration of the functional principle of an ulnar to musculocutaneous nerve transfer. (A) In a healthy person, there is a clear separation between activity in the motor cortex for functions of different nerves/joints as here the musculocutaneous nerve (red) and the ulnar nerve (blue). (B) After an injury of the musculocutaneous nerve, the biceps muscle cannot be activated, while the uninjured ulnar nerve (in blue) still functions. (C). After the Oberlin&#8217;s nerve transfer and re-innervation, fascicles of the ulnar nerve control the biceps muscles as well as all other muscles anatomically innervated by the ulnar nerve. Before cortical reorganization occurs, both muscles are activated together as there is no cortical separation between these nerve fibers (in blue). (D) With successful rehabilitation, the patient has learned to use certain cortical axons for &#8220;normal&#8221; ulnar nerve functions (in blue), while others (in purple) are now controlling the biceps muscle. This allows independent movement of both muscle groups. <a href="https://www.jove.com/files/ftp_upload/59840/59840fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
While comprehension of this concept is the foundation of successful rehabilitation, re-learning of new motor patterns can be challenging for patients and clinicians. This is due to the long duration of rehabilitation, the complexity of nerve regeneration and re-innervation and the limited amount of directly observable muscular activity during early re-innervation8. Apart from the changes in the peripheral nervous system, there is an increasing awareness among surgeons and therapists for the relevance of changes in the central nervous system (CNS), i.e., re-organization of the hand motor and sensory cortical areas occurring as a consequence to denervation11. When neural input to the CNS is deprived, the associated cortical area diminishes to a certain extent at the expense of adjacent areas12. Restoration of function, therefore, depends on the central recovery of its representation in the brain. Within the last years, the use of biofeedback methods8 and approaches to support cortical re-organization13,14,15 has led to extended possibilities in rehabilitation after nerve transfers. However, due to the complexity of post-surgical therapy, it is important to provide the right interventions at the right time13.
Therefore, the aim of this structured protocol for rehabilitation after selective nerve transfers is to provide a feasible and holistic approach to support motor recovery. It is based on current recommendations and the authors&#8217; experience with incorporating it in a clinical setting. The protocol is meant to guide medical doctors, occupational and physical therapists as well as other health professionals through the long-lasting rehabilitation process.
This structured protocol for motor rehabilitation was evaluated in a feasibility study8 in five patients with brachial plexus injuries as shown in Table 1. All of them received several nerve transfers (some in combination with nerve grafts) to restore upper extremity function. Therefore, for the sake of clarity, when describing specific interventions in this protocol, they refer to the upper limb. In detail, we take the Oberlin ulnar nerve transfer10 as an example, which was performed in patients 1-3. For this, we refer to parts of the ulnar nerve as being the donor nerve and the musculocutaneous nerve being the recipient nerve. Thus, the biceps and brachialis muscles are the recipient muscles being re-innervated by parts of the ulnar nerve. Functionally, this means that following a donor activation focused approach9, movements associated with ulnar nerve activity (such as hand closing or ulnar abduction of the wrist) are used for the activation of the biceps muscle directly after re-innervation. However, exercises based on this approach can be performed in other body parts as well. If special considerations are necessary to implement this in other body parts (e.g., the lower extremity), this is pointed out within the protocol.
Independent from the body part affected, therapy sessions should not exceed 30 min as muscles become easily fatigued shortly after re-innervation8 and successful training requires a patient&#8217;s full commitment and focus.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>EMG electrodes</td>
			<td>Otto bock Healthcare, Duderstadt, Germany</td>
			<td>electrodes 13E202 = 50</td>
			<td>The EMG electrodes used in this study were bipolar and included a ground and a 50 Hz filter. They were used with the Moby.</td>
		</tr>
		<tr>
			<td>Folding Mirror Therapy Box (Arm/Foot/Ankle)</td>
			<td>Reflex Pain Management Therapy Store</td>
			<td></td>
			<td>This box was used for mirror therapy.</td>
		</tr>
		<tr>
			<td>Myoboy</td>
			<td>Otto bock Healthcare, Duderstadt, Germany</td>
			<td>Myoboy</td>
			<td>This EMG Biofeedback device that can be used as stand alone device or with a computer. While this device was used in the presented pilot study, other (cheaper) devices for sEMG biofeedback training are available as well.</td>
		</tr>
		<tr>
			<td>Recognise[TM] Flash Cards</td>
			<td>noigroup</td>
			<td></td>
			<td>If no self-made cards for left-right discrimination are used, these can be purchased from noigroup.com. There, a mobile app for training is available as well.</td>
		</tr>
	</tbody>
</table>

structured motor rehabilitation after selective nerve transfers

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on the successful re-innervation of the targets in the periphery and on the motor re-learning process entailing cortical plasticity. While there is an increasing number of methods to improve rehabilitation, their routine implementation in a clinical setting remains a challenge due to their complexity and long duration. Therefore, recommendations for rehabilitation strategies are presented with the aim of guiding medical doctors and therapists through the long-lasting rehabilitation process and providing step-by-step instructions for supporting motor re-learning.
Directly after nerve transfer surgery, no motor function is present, and therapy should focus on promoting activity in the sensory-motor cortex areas of the paralyzed body part. After about two to six months (depending on the severity and modality of injury, the distance of nerve regeneration and many other factors), the first motor activity can be detected via electromyography (EMG). Within this phase of rehabilitation, multimodal feedback is used to re-learn the motor function. This is especially critical after nerve transfers, as muscle activation patterns change due to the altered neural connection. Finally, muscle strength should be sufficient to overcome gravity/resistance of antagonistic muscles and joint stiffness, and more functional tasks can be implemented in rehabilitation.

The described rehabilitation protocol was implemented in a clinical setting at the Medical University of Vienna and its feasibility was assessed in a previous study8.
As reported in our previous publication8, five patients participated in the trial to evaluate the feasibility and outcomes of such a program for motor rehabilitation after complex peripheral nerve injuries. Patient characteristics including injury and performed surgical reconstruction can be found in Table 1. All of the included patients suffered severe brachial plexus injuries. Thus, motor recovery without surgical intervention was deemed unlikely and direct nerve suture was not possible in any of the cases. The performed nerve transfers were chosen depending on the intact anatomy, and where possible, nerve transfers from agonistic muscles were performed. This was done to reduce the cognitive load during motor re-learning.
In order to evaluate the motor outcomes, the patients&#8217; muscle strength was evaluated prior to reconstructive surgery and after discharge from rehabilitation using the British Medical Research Council (BMRC) scale26.
The results presented in Table 2 show that all patients had an improved shoulder and elbow function after rehabilitation, allowing them to flex the arm against gravity. This is in line with earlier research, reporting that a majority of patients regain useful shoulder and elbow function after selective nerve transfers and rehabiliation3,27,28. However, two of the patients with an Oberlin&#8217;s ulnar nerve transfer included in this study, regained full elbow flexion strength (M5), which is better than described by Bertelli and Ghizoni (2004)29 who used the same surgical method. However, Ray et al. (2011)28 could also show full recovery of elbow function in some of the patients treated in their center. Therefore, the presented motor outcomes are similar or slightly better than those described in the literature. This indicates that this protocol contributes to good outcomes in proximal muscles, where re-innervation of the muscles is likely.
However, in more distal parts of the body, the full function could not be regained for all patients, which is in line with other research3,30. While we believe that motor re-education using a structured training protocol may facilitate motor rehabilitation by the central recovery of the hand&#8217;s representation in the brain, it has limited influence on the peripheral processes needed for the re-innervation of muscles after nerve transfer surgery. Thus, the authors propose the use of this protocol, if peripheral nerve re-innervation is expected, but do not believe it to promote nerve regeneration at the peripheral level.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case nr.</td>
			<td colspan="2">Sex, Age (years)</td>
			<td colspan="2">Type of Accident</td>
			<td colspan="2">Type of Lesion</td>
			<td colspan="2">Reconstructive surgeries for restoration of upper limb function</td>
		</tr>
		<tr>
			<td>1</td>
			<td colspan="2">m, 68</td>
			<td colspan="2">Motorcycle accident</td>
			<td colspan="2">Polytrauma; Global brachial plexopathy</td>
			<td colspan="2">Nerve grafts to bridge defect of MCN; thoracodorsal nerve grafts to bridge defect of axillary nerve; nerve grafts for posterior trunk reconstruction; Oberlin&#8217;s ulnar nerve transfer to MCN motor branch to the short head of the biceps</td>
		</tr>
		<tr>
			<td>2</td>
			<td colspan="2">m, 56</td>
			<td colspan="2">Bicycle accident</td>
			<td colspan="2">Nerve root avulsion of C5-C6</td>
			<td colspan="2">Oberlin&#8217;s ulnar nerve transfer to MCN motor branch for restoration of biceps function; transfer of radial triceps motor branch to axillary nerve</td>
		</tr>
		<tr>
			<td>3</td>
			<td colspan="2">m, 62</td>
			<td colspan="2">Bicycle accident</td>
			<td colspan="2">Extensive damage to superior trunk of the BP; traction injury of C7</td>
			<td colspan="2">XI-to-suprascapular nerve transfer; end-to-end transfer of phrenic nerve to C7; transfer of ulnar nerve fascicle to biceps motor branch of MCN; transfer of median nerve fascicle to brachialis motor branch of MCN; transfer of radial nerve fascicle to axillary nerve</td>
		</tr>
		<tr>
			<td>4</td>
			<td colspan="2">f, 22</td>
			<td colspan="2">Car accident</td>
			<td colspan="2">Nerve root avulsion of C7; damage to C8 and T1</td>
			<td colspan="2">Nerve grafts from C5 and C6 to MCN, median and radial nerve; nerve grafts from C8 to median, radial and ulnar nerve; nerve grafts from T1 to ulnar nerve</td>
		</tr>
		<tr>
			<td>5</td>
			<td colspan="2">f, 43</td>
			<td colspan="2">Minor trauma years after OBPL</td>
			<td colspan="2">Traction injury of superior and medial trunk of the BP</td>
			<td colspan="2">Nerve grafts to bridge defect of C5, C6 and C7 to restore elbow function and shoulder stability; transfer of median nerve fascicle to brachial motor branch of MCN</td>
		</tr>
	</tbody>
</table>
Table 1: Patient characteristics. Please note the following abbreviations: BP = brachial plexus; MCN = musculocutaneous nerve; OBPL = obstetrical brachial plexus lesion; OP = operation; XI = spinal accessory nerve. This table is adapted from Sturma et al. (2018)8.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Case nr.</td>
			<td colspan="2">Upper limb function including BMRC grades at baseline </td>
			<td colspan="2">Upper limb function including BMRC grades at follow-up</td>
			<td colspan="2">Time between nerve transfer surgery and first volitional sEMG activity</td>
			<td colspan="2">No. of Therapy Sessions in total (30 min each)</td>
		</tr>
		<tr>
			<td>1</td>
			<td colspan="2">Deltoid muscle: 0</td>
			<td colspan="2">Deltoid muscle: 2</td>
			<td colspan="2">5 months</td>
			<td colspan="2">25</td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Elbow flexion: 0</td>
			<td colspan="2">Elbow flexion: 3</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Triceps muscle: 0</td>
			<td colspan="2">Triceps muscle: 2</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">No active hand function</td>
			<td colspan="2">Wrist extension: 1</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2"></td>
			<td colspan="2">Finger extension: 2</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td>2</td>
			<td colspan="2">Elbow flexion: 1</td>
			<td colspan="2">Elbow flexion: 5</td>
			<td colspan="2">4 months</td>
			<td colspan="2">22</td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Deltoid muscle: 2-</td>
			<td colspan="2">Deltoid muscle: 5</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td>3</td>
			<td colspan="2">Elbow flexion: 0</td>
			<td colspan="2">Elbow flexion: 5</td>
			<td colspan="2">3 months</td>
			<td colspan="2">30</td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Deltoid muscle: 0</td>
			<td colspan="2">Deltoid muscle: 4</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Triceps muscle: 3</td>
			<td colspan="2">Triceps muscle: 5</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Wrist extension: 3+</td>
			<td colspan="2">Wrist extension: 5</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Finger flexion: 3+</td>
			<td colspan="2">Finger flexion: 5</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td>4</td>
			<td colspan="2">Elbow flexion: 0</td>
			<td colspan="2">Elbow flexion: 3+</td>
			<td colspan="2">5 months</td>
			<td colspan="2">20</td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Triceps muscle: 0</td>
			<td colspan="2">Triceps muscle: 2</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">No active hand function</td>
			<td colspan="2">Wrist flexion: 3</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2"></td>
			<td colspan="2">Finger flexion (ulnar FDP part): 3</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td>5</td>
			<td colspan="2">Elbow flexion: 0</td>
			<td colspan="2">Elbow flexion: 3</td>
			<td colspan="2">4 months</td>
			<td colspan="2">18</td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Deltoid muscle: 2</td>
			<td colspan="2">Deltoid muscle: 2</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td></td>
			<td colspan="2">Triceps muscle: 3+</td>
			<td colspan="2">Triceps muscle: 4</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
		</tr>
		<tr>
			<td>Mean (&#177;SD)</td>
			<td colspan="2"></td>
			<td colspan="2"></td>
			<td colspan="2">4.2 &#177; 0.75 months</td>
			<td colspan="2">23 &#177; 4.20</td>
		</tr>
	</tbody>
</table>
Table 2: Motor outcomes of the rehabilitation protocol. There was no functional impairment of the muscles not included in the table. In all patients, shoulder and elbow function were impaired at baseline and improved to follow-up. Additionally, the time between surgery and first volitional sEMG activity, as well as the number of therapy sessions for each patient are presented. This table is adapted from Sturma et al. (2018)8.
Supplementary File.&#160;<a href="https://www.jove.com/files/ftp_upload/59840/NT-Reha_leaflet.pdf">Please click here to download the file.</a>

Watch this Scientific Journal Video about Structured Motor Rehabilitation After Selective Nerve Transfers at JoVE.com

Structured Motor Rehabilitation After Selective Nerve Transfers

Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve&#8217;s target.

After severe nerve injuries, selective nerve transfers provide an opportunity to restore motor and sensory function. Functional recovery depends both on ...

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21.3K Views.  Medical University of Vienna. Here, we present a protocol for the motor rehabilitation of patients with severe nerve injuries and selective nerve transfer surgery. It aims at restoring the motor function proposing several stages in patient education, early-stage therapy after surgery and interventions for rehabilitation after successful re-innervation of the nerve’s target.

Video: Structured Motor Rehabilitation After Selective Nerve Transfers

Methods to Quantify Pharmacologically Induced Alterations in Motor Function in Human Incomplete SCI

Spinal cord injury (SCI) is a debilitating disorder, which produces profound deficits in volitional motor control. Following medical stabilization, recovery from SCI typically involves long term rehabilitation. While recovery of walking ability is a primary goal in many patients early after injury, those with a motor incomplete SCI, indicating partial preservation of volitional control, may have the sufficient residual descending pathways necessary to attain this goal. However, despite physical interventions, motor impairments including weakness, and the manifestation of abnormal involuntary reflex activity, called spasticity or spasms, are thought to contribute to reduced walking recovery. Doctrinaire thought suggests that remediation of this abnormal motor reflexes associated with SCI will produce functional benefits to the patient. For example, physicians and therapists will provide specific pharmacological or physical interventions directed towards reducing spasticity or spasms, although there continues to be little empirical data suggesting that these strategies improve walking ability.
In the past few decades, accumulating data has suggested that specific neuromodulatory agents, including agents which mimic or facilitate the actions of the monoamines, including serotonin (5HT) and norepinephrine (NE), can initiate or augment walking behaviors in animal models of SCI. Interestingly, many of these agents, particularly 5HTergic agonists, can markedly increase spinal excitability, which in turn also increases reflex activity in these animals. Counterintuitive to traditional theories of recovery following human SCI, the empirical evidence from basic science experiments suggest that this reflex hyper excitability and generation of locomotor behaviors are driven in parallel by neuromodulatory inputs (5HT) and may be necessary for functional recovery following SCI. 
The application of this novel concept derived from basic scientific studies to promote recovery following human SCI would appear to be seamless, although the direct translation of the findings can be extremely challenging. Specifically, in the animal models, an implanted catheter facilitates delivery of very specific 5HT agonist compounds directly onto the spinal circuitry. The translation of this technique to humans is hindered by the lack of specific surgical techniques or available pharmacological agents directed towards 5HT receptor subtypes that are safe and effective for human clinical trials. However, oral administration of commonly available 5HTergic agents, such as selective serotonin reuptake inhibitors (SSRIs), may be a viable option to increase central 5HT concentrations in order to facilitate walking recovery in humans. Systematic quantification of how these SSRIs modulate human motor behaviors following SCI, with a specific focus on strength, reflexes, and the recovery of walking ability, are missing.
This video demonstration is a progressive attempt to systematically and quantitatively assess the modulation of reflex activity, volitional strength and ambulation following the acute oral administration of an SSRI in human SCI. Agents are applied on single days to assess the immediate effects on motor function in this patient population, with long-term studies involving repeated drug administration combined with intensive physical interventions.

This video demonstrates modulation of reflex activity, volitional strength and ambulation through clinical and quantitative assessments in individuals with motor incomplete SCI as a result of acute oral administration of a serotonin reuptake inhibitor (SSRI).

Spinal cord injury (SCI) is a debilitating disorder, which produces profound deficits in volitional motor control. Following medical stabilization, ...

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8 
This video demonstrates a protocol for MMT, which has been taught to &ge;43 research staff who have performed &gt;800 assessments on &gt;280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups. This video demonstrates MMT using the 6-point Medical Research Council scale.

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, ...

Breathing-controlled Electrical Stimulation (BreEStim) for Management of Neuropathic Pain and Spasticity

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. It has been extensively used in various clinical settings. Based upon recent discoveries related to the systemic effects of voluntary breathing and intrinsic physiological interactions among systems during voluntary breathing, a new EStim protocol, Breathing-controlled Electrical Stimulation (BreEStim), has been developed to augment the effects of electrical stimulation. In BreEStim, a single-pulse electrical stimulus is triggered and delivered to the target area when the airflow rate of an isolated voluntary inspiration reaches the threshold. BreEStim integrates intrinsic physiological interactions that are activated during voluntary breathing and has demonstrated excellent clinical efficacy. Two representative applications of BreEStim are reported with detailed protocols: management of post-stroke finger flexor spasticity and neuropathic pain in spinal cord injury.

Breathing-controlled Electrical Stimulation BreEStim for Management of Neuropathic Pain and Spasticity

The purpose is to present a new method, breathing-control electrical stimulation (BreEStim) for management of neuropathic pain and spasticity.

Electrical stimulation (EStim) refers to the application of electrical current to muscles or nerves in order to achieve functional and therapeutic goals. ...

Brachial Artery Catheterization in Swine

The video describes in detail the catheterization of the distal brachial artery in swine. This technique enables researchers to measure arterial blood pressure continuously and collect arterial blood samples to assess arterial blood gas measurements. Arterial blood pressures and arterial blood gases are important physiological parameters to monitor during experimental procedures. In swine, four common methods of arterial catheterization have been described, including catheterization of the carotid, femoral, auricular, and medial saphenous arteries. Each of these techniques have advantages, such as ease of access for the auricular artery, and disadvantages that include deep tissue dissection for carotid artery catheterization. The described alternative method of arterial catheterization in swine, the catheterization of the distal aspect of the brachial artery, is a rapid procedure that requires relatively minimal tissue dissection and provides information that is in line with data collected from other arterial catheterization sites. The procedure uses a medial approach along an oblique plane of the lower brachium, positioned between the olecranon and the flexor aspect of the elbow joint, and this approach allows researchers the major advantage of unimpeded freedom for procedures that involve the caudoventral, caudodorsal back, or hind limbs of the pig. Due to the location of the upper forelimb of the catheterized vessel and potential challenges of effective homeostasis following catheter removal from the artery, this technique may be limited to non-recovery procedures.

The video describes in detail the catheterization of the distal brachial artery in swine. This procedure accurately measures arterial blood pressure and is a simple and fast method to collect samples for arterial blood gas measurements.

The video describes in detail the catheterization of the distal brachial artery in swine. This technique enables researchers to measure arterial blood ...

A Non-Invasive Method for Generating the Cyclic Loading-Induced Intra-Articular Cartilage Lesion Model of the Rat Knee

The pathophysiology of primary osteoarthritis (OA) remains unclear. However, a specific subclassification of OA in relatively younger age groups is likely correlated with a history of articular cartilage damage and ligament avulsion. Surgical animal models of OA of the knee play an important role in understanding the onset and progression of post-traumatic OA and aid in the development of novel therapies for this disease. However, non-surgical models have been recently considered to avoid traumatic inflammation that could affect the evaluation of the intervention. 
In this study, an intra-articular cartilage lesion rat model induced by in vivo cyclic compressive loading was developed, which allowed researchers to (1) determine the optimal magnitude, speed, and duration of load that could cause focal cartilage damage; (2) assess post-traumatic spatiotemporal pathological changes in chondrocyte vitality; and (3) evaluate the histological expression of destructive or protective molecules that are involved in the adaptation and repair mechanisms against joint compressive loads. This report describes the experimental protocol for this novel cartilage lesion in a rat model.

Here, we present the cyclic loading-induced intra-articular cartilage lesion model of the rat knee, generated by 60 cyclic compressions over 20 N, resulting in damage to the femoral condylar cartilage in rats.

The pathophysiology of primary osteoarthritis (OA) remains unclear. However, a specific subclassification of OA in relatively younger age groups is likely ...

Therapy Interventions for Upper Limb Amputees Undergoing Selective Nerve Transfers

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective activation of muscle units is made possible by surgically re-routing nerves, yielding a high number of independent myoelectric control signals. However, this intervention requires careful patient selection and specific rehabilitation therapy. Here a rehabilitation protocol is presented for high-level upper limb amputees undergoing TMR, based on an expert Delphi study. Interventions before surgery include detailed patient assessment and general measures for pain control, muscle endurance and strength, balance, and range of motion of the remaining joints. After surgery, additional therapeutic interventions focus on edema control and scar treatment and the selective activation of cortical areas responsible for upper limb control. Following successful&#160;reinnervation of target muscles, surface electromyographic (sEMG) biofeedback is used to train the activation of the novel muscular units. Later on, a table-top prosthesis may provide the first experience of prosthetic control. After fitting the actual prosthesis, training includes repetitive drills without objects, object manipulation, and finally, activities of daily living. Ultimately, regular patient appointments and functional assessments allow tracking prosthetic function and enabling early interventions if malfunctioning.

This work presents a protocol to enhance prosthetic function after selective nerve transfer surgery. Rehabilitation interventions include patient information and selection, support of wound healing, cortical re-activation of sensory-motor areas of the upper limb, training of selective muscle activation, prosthetic handling in daily life, and regular follow-up assessments.

Targeted Muscle Reinnervation (TMR) improves the biological control interface for myoelectric prostheses after above-elbow amputation. Selective ...

Iris Fixation via External Pentagram Suturing

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both oculopathy and complicated post anterior segment surgery. This can impact visual function and lead to bullous keratopathy, making it one of the most complex clinical problems. Conventional anterior chamber plasty will partially create the anterior chamber, but the anterior chamber disappears again in some cases. The main reasons are: (1) the iris lens diaphragm is loose with atrophied and tension-free iris so that the aqueous humor circulation will push and squeeze the iris forward; (2) the effect of "roller" formed in the process of inflammation or restoration will change the iris structure from peripheral anterior synechia (PAS) to extensive anterior synechia again; (3) the fibration will result in synechia from iris to the cornea. In such cases, corneal endothelium deficiency can't stop the aqueous humor from entering the cornea. This results in persistent corneal edema post-conventional anterior chamber plasty, resulting in progressive rubbing and lachrymation. Therefore, anterior chamber plasty is not the first choice for patients without surgical indications of Descemet's stripping automated endothelial keratoplasty (DSAEK). However, this can be performed in patients with surgical indications who plan to receive DSAEK. A unique method of iris fixation via external pentagram suturing anterior chamber plasty (PSACP) is described here. The present technique is also compared with the conventional anterior chamber plasty. PSACP and DSAEK might be an effective way to cure the bullous keratopathy with extensive anterior synechia of the iris and disappeared anterior chamber.

Iris Fixation via External Pentagram Suturing

The present protocol describes how a 10-0 polypropylene suture crosses the anterior surface of the iris, forming a pentagram to prevent both iris and pupil from moving toward the cornea. This can be combined with subsequent keratoplasty to cure bullous keratopathy with extensive anterior synechia of the iris.

Extensive anterior synechia of the iris can result in the gradual disappearance of the anterior chamber. It is one of the most common outcomes of both ...

Improving FSN Therapy in the Rat Model&#58; Minimizing Discomfort and Maximizing Efficiency

Efficacy of Fu's Subcutaneous Needling on Sciatic Nerve Pain: Behavioral and Electrophysiological Changes in a Chronic Constriction Injury Rat Model

Fu&#39;s subcutaneous needling (FSN), an invented acupuncture technique from traditional Chinese medicine, is used worldwide for pain relief. However, the mechanisms of action are still not fully understood. During FSN treatment, the FSN needle is inserted and retained in the subcutaneous tissues for a long duration with a swaying movement. However, challenges arise from maintaining a posture while manipulating FSN in animal models (e.g., rats) for researchers. Uncomfortable treatment can lead to fear and resistance to FSN needles, increasing the risk of injury and may even affect research data. Anesthesia may also affect the study results too. Hence, there is a need for strategies in FSN therapy on animals that minimize injury during the intervention. This study employs a chronic constriction injury model in Sprague-Dawley rats to induce neuropathic pain. This model replicates the pain induced by nerve injury observed in humans through surgical constriction of a peripheral nerve, mimicking the compression or entrapment seen in conditions such as nerve compression syndromes and peripheral neuropathies. We introduce an appropriate manipulation for easily inserting an FSN needle into the subcutaneous layer of the animal&#39;s body, including needle insertion and direction, needle retention, and swaying movement. Minimizing the rat&#39;s discomfort prevents the rat from being tense, which causes the muscle to contract and hinder the entry of the needle and improves the study efficiency.

Author Spotlight: Unveiling the Therapeutic Effects of FSN Treatment &#8211; Bridging Research and Clinical Applications in Neuropathic Pain

We present a protocol for using Fu's subcutaneous needling in a chronic constriction injury model to induce sciatic nerve pain in rats.

Fu&#39;s subcutaneous needling (FSN), an invented acupuncture technique from traditional Chinese medicine, is used worldwide for pain relief. However, the ...

Preventing Posterior Capsular Opacification Through IOL Rotation in Cataract Surgeries

Rotating the Intraocular Lens to Prevent Posterior Capsular Opacification in Cataract Surgeries

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and migration of lens epithelial cells and can affect long-term visual outcomes significantly. The most effective treatment for PCO is neodymium-doped yttrium aluminum garnet (Nd:YAG) laser capsulotomy; however, this treatment is associated with posterior segment complication and can break the stability of capsular bag, affecting the position and function of trifocal or toric intraocular lenses (IOLs). Advances in surgical procedures, IOL design, and pharmacy have reduced the rate of PCO in recent years, concentrating on the inhibition of proliferative lens epithelial cells (LECs). This protocol aimed to clear LECs more thoroughly during phacoemulsification and IOL implantation. The first several steps, including clear corneal incision, continuous circular capsulorhexis, hydrodissection, hydrodelineation, and phacoemulsification, were completed as conventional procedures. After placing the IOL into the capsular bag, rotation of the IOL by at least 360&#176; was performed using an irrigation/aspiration tip or a hook, with slight stress on the posterior capsule. Some residuals occurred in the originally transparent capsular bag after rotation of the IOLs. Then, these materials and the viscoelastic were cleared completely using an irrigation/aspiration system. A clear posterior capsule was observed after the surgery in patients undergoing this method. This method of rotating IOLs is a simple, effective, and safe way to prevent PCO by clearing residual LECs and can be carried out without extra tools or skills.

Author Spotlight: Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation 

The present protocol describes removing residual epithelial cells by rotating the intraocular lens in extracapsular cataract surgery without extra tools for preventing posterior capsular opacification.

Posterior capsule opacification (PCO) is a common postoperative complication of extracapsular cataract surgery, which is caused by the proliferation and ...

A Massager Based on Ding's Roll Manipulation to Treat Muscle Injury in a Rat Model

Mimicking Ding's Roll Method on Notexin-Induced Muscle Injury in Rats

Ding's roll method is one of the most commonly used manipulations in traditional Chinese massage (Tuina) clinics and one of the most influential contemporary Tuina manipulations in China. It is based on the traditional rolling method commonly used in the one finger Zen genre and named Ding's roll method. Due to its anti-inflammatory and blood circulation-promoting effects, Ding's rolling method has sound therapeutic effects on myopathy. Because of the large area of force applied to human skin, Ding's roll method is challenging to perform on experimental animals with small skin areas, such as rats and rabbits. Additionally, the strength of Tuina applied to the human body differs from that applied to experimental animals, so it may happen that the strength is too high or too low to achieve the therapeutic effect of Tuina during the experiment. This experiment aims to create a simple massager suitable for rats based on Ding's rolling manipulation parameters (strength, frequency, Tuina duration). The device can standardize manipulation in animal experiments and reduce the variation in Tuina force applied to different animals due to subjective factors. A rat model of notexin-induced skeletal muscle injury was established, and plasma injury markers creatine kinase (CK) and fatty acid binding protein 3 (FABP3) were used to assess the therapeutic effect of Tuina on skeletal muscle injury. The results showed that this Tuina massager could reduce the levels of CK and FABP3 expression and slow down the degree of skeletal muscle injury. Therefore, the Tuina massager described here, mimicking Ding's roll method, contributes to standardizing Tuina manipulation in experimental research and is of great help for subsequent research on the molecular mechanism of Tuina for myopathy.

Author Spotlight: Performing Tuina Massage in Rats Using a Self-Made Massager 

This protocol describes a simple device that mimics Ding's roll method, establishes a rat model of skeletal muscle injury, and uses hematoxylin-eosin staining to observe the pathology of damaged tissue and enzyme-linked immunosorbent assay to detect changes in serum damage markers.