Neuromuscular Stimulation Research Articles

Developing Novel Therapies for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 7]: Opportunities From Restorative Neurobiology.

Study designNarrative review.ObjectivesTo provide an overview of contemporary therapies for the James Lind Alliance priority setting partnership for degenerative cervical myelopathy (DCM) question: ‘Can novel therapies, including stem-cell, gene, pharmacological and neuroprotective therapies, be identified to improve the health and wellbeing of people living with DCM and slow down disease progression?’MethodsA review of the literature was conducted to outline the pathophysiology of DCM and present contemporary therapies that may hold therapeutic value in 3 broad categories of neuroprotection, neuroregeneration, and neuromodulation.ResultsChronic spinal cord compression leads to ischaemia, neuroinflammation, demyelination, and neuronal loss. Surgical intervention may halt progression and improve symptoms, though the majority do not make a full recovery leading to lifelong disability. Neuroprotective agents disrupt deleterious secondary injury pathways, and one agent, Riluzole, has undergone Phase-III investigation in DCM. Although it did not show efficacy on the primary outcome modified Japanese Orthopaedic Association scale, it showed promising results in pain reduction. Regenerative approaches are in the early stage, with one agent, Ibudilast, currently in a phase-III investigation. Neuromodulation approaches aim to therapeutically alter the state of spinal cord excitation by electrical stimulation with a variety of approaches. Case studies using electrical neuromuscular and spinal cord stimulation have shown positive therapeutic utility.ConclusionThere is limited research into interventions in the 3 broad areas of neuroprotection, neuroregeneration, and neuromodulation for DCM. Contemporary and novel therapies for DCM are now a top 10 priority, and whilst research in these areas is limited in DCM, it is hoped that this review will encourage research into this priority.

Neuromuscular Stimulation as an Intervention Tool for Recovery from Upper Limb Paresis after Stroke and the Neural Basis

Neuromodulators at the periphery, such as neuromuscular electrical stimulation (NMES), have been developed as add-on tools to regain upper extremity (UE) paresis after stroke, but this recovery has often been limited. To overcome these limits, novel strategies to enhance neural reorganization and functional recovery are needed. This review aims to discuss possible strategies for enhancing the benefits of NMES. To date, NMES studies have involved some therapeutic concerns that have been addressed under various conditions, such as the time of post-stroke and stroke severity and/or with heterogeneous stimulation parameters, such as target muscles, doses or durations of treatment and outcome measures. We began by identifying factors sensitive to NMES benefits among heterogeneous conditions and parameters, based on the “progress rate (PR)”, defined as the gains in UE function scores per intervention duration. Our analysis disclosed that the benefits might be affected by the target muscles, stroke severity and time period after stroke. Likewise, repetitive peripheral neuromuscular magnetic stimulation (rPMS) is expected to facilitate motor recovery, as already demonstrated by a successful study. In parallel, our efforts should be devoted to further understanding the precise neural mechanism of how neuromodulators make UE function recovery occur, thereby leading to overcoming the limits. In this study, we discuss the possible neural mechanisms.

Prediction of Force Recruitment of Neuromuscular Magnetic Stimulation From 3D Field Model of the Thigh.

Neuromuscular magnetic stimulation is a promising tool in neurorehabilitation due to its deeper penetration, notably lower distress, and respectable force levels compared to surface electrical stimulation. However, this method faces great challenges from a technological perspective. The systematic design of better equipment and the incorporation into modern training setups requires better understanding of the mechanisms and predictive quantitative models of the recruited forces. This article proposes a model for simulating the force recruitment in isometric muscle stimulation of the thigh extensors based on previous theoretical and experimental findings. The model couples a 3D field model for the physics with a parametric recruitment model. This parametric recruitment model is identified with a mixed-effects design to learn the most likely model based on available experimental data with a wide range of field conditions. This approach intentionally keeps the model as mathematically simple and statistically parsimonious as possible in order to avoid over-fitting. The work demonstrates that the force recruitment particularly depends on the effective, i.e., fiber-related cross section of the muscles, and that the local median electric field threshold amounts to about 65 V/m, which agrees well with values for magnetic stimulation in the brain. The coupled model is able to accurately predict key phenomena observed so far, such as a threshold shift for different distances between coil and body, the different recruiting performance of various coils with available measurement data in the literature, and the saturation behavior with its onset amplitude. The presented recruitment model could also be readily incorporated into dynamic models for biomechanics as soon as sufficient experimental data are available for calibration.

Comparison between the effects of Maitland's mobilization versus its combination with vastus medialis oblique neuromuscular stimulation on two scales (NPRS & WOMAC) in knee osteoarthritis patients.

Osteoarthritis (OA) is the most common form of arthritis that increases with age affecting the population from the middle age to the elderly. The present study was undertaken to find whether neuromuscular stimulation of vastus medialis oblique (VMO) in combination with Maitland's mobilization and exercises was more effective as compared to Maitland's mobilization with exercises alone in patients with knee OA. Sixty patients with knee OA were purposively selected and randomly distributed to two groups that received an intervention for eight weeks. Group A patients received Maitland's mobilization in combination with exercises and group B patients received the same intervention as group A in combination with neuromuscular stimulation of VMO muscle. After eight weeks, outcome measures, i.e. Numeric Pain Rating Scale (NPRS) and Western Ontario and McMaster University Osteoarthritis Index (WOMAC) index, were reassessed. Both groups showed significant (P<0.05) within-group improvement in the knee pain levels and stiffness as reflected by NPRS and WOMAC index. Patients of both the groups (A and B) were found to be improving significantly in pain and disability, group A patients receiving Maitland's mobilization in combination with exercises were found to get more relief in pain and disability.

Effect of microcurrent electrical neuromuscular stimulation on the autonomic nervous balance : examination by using a wearable sensor

Effect of microcurrent electrical neuromuscular stimulation on the autonomic nervous balance : examination by using a wearable sensor

Pilot Trial of Neuromuscular Stimulation in Human Subjects with Chronic Venous Disease.

IntroductionNeuromuscular stimulation (NMES) has been shown to improve peripheral blood flow in healthy people. We investigated the effect of bilateral leg NMES on the symptoms of chronic venous disease.MethodsForty subjects were recruited from four groups: healthy, superficial insufficiency, deep insufficiency, and deep obstruction. Haemodynamic venous measurements were taken from the right femoral vein with ultrasound, laser Doppler fluximetry from the left hand and foot. Devices were then worn for 4–6 hours per day, for 6 weeks. Haemodynamic measurements were repeated at week 6. Quality of life questionnaires were taken at week 0, 6 and 8.ResultsThe mean age was 48.7, BMI 28.6kg/m2, and maximum calf circumference 39.0 cm. Twenty-four subjects were men. NMES increased femoral vein peak velocity, TAMV and volume flow by 55%, 20%, 36% at 20 minutes (all p<0.05), which was enhanced at week 6 (PV and TAMV p<0.05). Mean increases in arm and leg fluximetry were 71% and 194% (both p<0.01). Leg swelling was reduced by mean 252.7 mL (13%, p<0.05) overall; 338.9 mL (16%, p<0.05) in venous disease. For those with venous pathology, scores for disease specific and generic quality of life questionnaires improved. Those with C4-6 disease benefitted the most, with improvements in VDS score of 1, AVVQ of 6, and SF-12 of 10.ConclusionNMES improves venous haemodynamic parameters in chronic venous disease, which is enhanced by regular use. NMES reduces leg oedema, improves blood supply to the skin of the foot, and may positively affect quality of life.Clinical TrialsThis trial was registered with www.clinicaltrials.org.uk (NCT02137499).

Feedback Control of Upright Seating with Functional Neuromuscular Stimulation during a Functional Task after Spinal Cord Injury: A Case Study.

Seated stability is a major concern of individuals with trunk paralysis. Trunk paralysis is commonly caused by spinal cord injuries (SCI) at or above the thoracic spine. Current methods to improve stability restrict the movement of the user by constraining their trunk to an upright position. Feedback control of functional neuromuscular stimulation (FNS) can help maintain seated stability while still allowing the user to perform movements to accomplish functional tasks. In this study, an individual with a SCI (C7, AIS B) and an implanted stimulator capable of recruiting trunk and hip musculature unilaterally moved a weighted jar on a countertop to and from three prescribed stations directly in front, laterally, and across midline. For comparison, the tasks were performed with constant baseline stimulation and with feedback modulated stimulation based on the tilt of the trunk obtained from an external accelerometer fed into two PID controllers; one for forward trunk pitch and the other for lateral roll. The trunk pitch and roll angles were obtained through motion capture cameras and various measures of postural sway (95% fitted ellipse area, root mean squared (RMS), path length) and the repeatability (coefficient of variation (CoV), variance ratio (VR)) were calculated. Feedback control significantly increased RMS of trunk movement along the major axis of the fitted ellipse, but decreased RMS values during bending along the minor axis of motion. As a result, the fitted ellipse area decreased when deploying the jar to one of the stations and increased with the other two. The CoV indicated reduced variation in the presence of feedback controlled stimulation for all stations, and VR showed higher repeatability in trunk pitch. Plots of the trunk pitch and roll revealed a faster return to upright motion due to feedback stimulation.Clinical relevance- Feedback control in combination with FNS is a viable method to improve seated stability while still allowing dynamic movements in individuals with a SCI, thus addressing a major concern of the population.

Effect of proprioceptive sensation and feedback required for motor learning on function, activity, and daily life behavior of patients after nerve injury

Purpose: This study investigated the effects of modified mirror therapy and taping therapy for providing feedback on upper extremity function, activity, and daily activities of stroke patients. Methods: This study was conducted with 20 stroke patients and randomly assigned 10 subjects to the experimental group and 10 to the control group. In the experimental group, after proprioceptive neuromuscular stimulation treatment, the mirror therapy program was implemented. In the control group, upper extremity taping was performed before proprioceptive neuromuscular facilitation treatment. In this study, a prior evaluation using JTT, FIM, and MAL was performed before intervention to evaluate the patient's function and daily life behavior. Post-tests were performed after the last treatment. Results: In the paired-sample T-test used for within-group comparison of JTTs, FIM, and MAL, there was a significant difference between pre- and post-test for all groups. But there was no statistically significant difference between experimental group 1 and experimental group 2 in an independent t-test conducted to compare the effect sizes of treatments. Conclusion: In other words, by applying mirror therapy and taping therapy that can increase proprioceptive sensation and feedback information in stroke patients, upper extremity function and daily activities can be increased.

Neuromodulation for functional restoration: recent advances and future perspectives

This mini-review assessed recent studies of spinal cord stimulation and neuromuscular stimulation in spinal cord injury in order to provide an overview of recent advances in neuromodulation for functional restoration. Possible mechanisms of such motor recovery were analyzed, ways to improve neuromodulation for functional restoration were discussed, and future perspectives were outlined in this paper. Recent advancements in neuromodulation such as spinal cord stimulation and neuromuscular stimulation in spinal cord injury have made it possible for patients with incurable complete paralysis to recover motor function. The progress of recent neuromodulation studies in spinal cord injury have demonstrated the value and potential of neuromodulation in functional restoration. The effectiveness and precision of neuromodulation can be further improved by techniques such as closed-loop control, optogenetics, multi-modal stimulation and neuroimmune modulation, while its adverse effects can be reduced (e.g., by optimizing parameters) or minimized (e.g., by using non-invasive techniques). This has opened up new possibilities to use neuromodulation for other incurable neurological diseases such as Parkinson’s disease and multiple sclerosis. Neuromodulation has great potential for restoring lost functions and reestablishing physiological homeostasis. To reach its full potential, much learning, research and development is needed. As neuromodulation technology advances, it is foreseeable that neuromodulation will achieve significant clinical effectiveness in functional restoration in the near future, which will bring cure to patients with incurable neurological diseases and relieve them from suffering.

Rehabilitation Treatment Outcomes among Stroke Patients with Dysphagia

Objectives: Dysphagia is a major complaint following stroke and occurs 37-78% of the time. It is associated with poor clinical outcome and high mortality rates. There are approximately 220-290 new stroke cases per 100.000 person-years in Mongolia and 178-260 in China. Rapidly changing lifestyles, socioeconomic status, stress, and increasing cardiovascular diseases are leading causes of stroke in the world and its diagnosis and treatment are one of the challenges of health care. Therefore, we aimed to characterize the swallow status and treatment outcome among dysphagic patients. Methods: The study was conducted in a hospital-based, cross-sectional method. Study participants were obtained from the Affiliated Hospital of Inner Mongolian University for the Nationalities between July 2018 and March 2019. All patients were randomly divided into three treatment groups. 149 patients with dysphagia were evaluated by video fluoroscopic assessment (VFSS) before and after the treatment. Results: In total, 149 participants (mean age = 59.70 ± 9.55 years) aged between 34-77 were obtained in this study. There were no statistically significant differences between the three groups in age (p = 0.583). The data showed a statistically significant positive treatment effect for all three groups (p = 0.000). The VFSS score was 7.94 ± 1.04 in the A group, 7.52 ± 1.12 in the B group, and 8.36 ± 0.98 in the C group after the treatment. The VFSS score shows a statistically significant difference, after the treatment (p = 0.000). Conclusion: Rehabilitation treatment combined with neuromuscular electrical simulation shows a better outcome than rehabilitation treatment without combined neuromuscular stimulation among stroke patients with dysphagia. The assessment of swallowing function should include both clinical and video fluoroscopic evaluation. Video fluoroscopic features are important predictors of swallowing abnormalities and complications.

A versatile system for neuromuscular stimulation and recording in the mouse model using a lightweight magnetically coupled headmount

Neural stimulation and recording in rodents are common methods to better understand the nervous system and improve the quality of life of individuals who are suffering from neurological disorders (e.g., epilepsy), as well as for permanent reduction of chronic pain in patients with neuropathic pain and spinal-cord injury. This method requires a neural interface (e.g., a headmount) to couple the implanted neural device with instrumentation system. The size and the total weight of such headmounts should be designed in a way to minimize its effect on the movement of the animal. This is a crucial factor in gait, kinematic, and behavioral neuroscience studies of freely moving mice. Here we introduce a lightweight ‘snap-in’ electro-magnetic headmount that is extremely small, and uses strong neodymium magnetics to enable a reliable connection without sacrificing the lightweight of the device. Additionally, the headmount requires minimal surgical intervention during the implantation, resulting in minimal tissue damage. The device has demonstrated itself to be robust, and successfully provided direct electrical stimulation of nerve and electrical muscle stimulation and recording, as well as powering implanted LEDs for optogenetic use scenarios.

Neural Networks Trained via Reinforcement Learning Stabilize Walking of a Three-Dimensional Biped Model With Exoskeleton Applications.

Our group is developing a cyber-physical walking system (CPWS) for people paralyzed by spinal cord injuries (SCI). The current CPWS consists of a functional neuromuscular stimulation (FNS) system and a powered lower-limb exoskeleton for walking with leg movements in the sagittal plane. We are developing neural control systems that learn to assist the user of this CPWS to walk with stability. In a previous publication (Liu et al., Biomimetics, 2019, 4, 28), we showed a neural controller that stabilized a simulated biped in the sagittal plane. We are considering adding degrees of freedom to the CPWS to allow more natural walking movements and improved stability. Thus, in this paper, we present a new neural network enhanced control system that stabilizes a three-dimensional simulated biped model of a human wearing an exoskeleton. Results show that it stabilizes human/exoskeleton models and is robust to impact disturbances. The simulated biped walks at a steady pace in a range of typical human ambulatory speeds from 0.7 to 1.3 m/s, follows waypoints at a precision of 0.3 m, remains stable, and continues walking forward despite impact disturbances and adapts its speed to compensate for persistent external disturbances. Furthermore, the neural network controller stabilizes human models of different statures from 1.4 to 2.2 m tall without any changes to the control parameters. Please see videos at the following link: 3D biped walking control.

Improving motor imagery classification during induced motor perturbations

Objective. Motor imagery is the mental simulation of movements. It is a common paradigm to design brain-computer interfaces (BCIs) that elicits the modulation of brain oscillatory activity similar to real, passive and induced movements. In this study, we used peripheral stimulation to provoke movements of one limb during the performance of motor imagery tasks. Unlike other works, in which induced movements are used to support the BCI operation, our goal was to test and improve the robustness of motor imagery based BCI systems to perturbations caused by artificially generated movements. Approach. We performed a BCI session with ten participants who carried out motor imagery of three limbs. In some of the trials, one of the arms was moved by neuromuscular stimulation. We analysed 2-class motor imagery classifications with and without movement perturbations. We investigated the performance decrease produced by these disturbances and designed different computational strategies to attenuate the observed classification accuracy drop. Main results. When the movement was induced in a limb not coincident with the motor imagery classes, extracting oscillatory sources of the movement imagination tasks resulted in BCI performance being similar to the control (undisturbed) condition; when the movement was induced in a limb also involved in the motor imagery tasks, the performance drop was significantly alleviated by spatially filtering out the neural noise caused by the stimulation. We also show that the loss of BCI accuracy was accompanied by weaker power of the sensorimotor rhythm. Importantly, this residual power could be used to predict whether a BCI user will perform with sufficient accuracy under the movement disturbances. Significance. We provide methods to ameliorate and even eliminate motor related afferent disturbances during the performance of motor imagery tasks. This can help improving the reliability of current motor imagery based BCI systems.

Peculiarities of Neurostimulation by Intense Nanosecond Pulsed Electric Fields: How to Avoid Firing in Peripheral Nerve Fibers.

Intense pulsed electric fields (PEF) are a novel modality for the efficient and targeted ablation of tumors by electroporation. The major adverse side effects of PEF therapies are strong involuntary muscle contractions and pain. Nanosecond-range PEF (nsPEF) are less efficient at neurostimulation and can be employed to minimize such side effects. We quantified the impact of the electrode configuration, PEF strength (up to 20 kV/cm), repetition rate (up to 3 MHz), bi- and triphasic pulse shapes, and pulse duration (down to 10 ns) on eliciting compound action potentials (CAPs) in nerve fibers. The excitation thresholds for single unipolar but not bipolar stimuli followed the classic strength–duration dependence. The addition of the opposite polarity phase for nsPEF increased the excitation threshold, with symmetrical bipolar nsPEF being the least efficient. Stimulation by nsPEF bursts decreased the excitation threshold as a power function above a critical duty cycle of 0.1%. The threshold reduction was much weaker for symmetrical bipolar nsPEF. Supramaximal stimulation by high-rate nsPEF bursts elicited only a single CAP as long as the burst duration did not exceed the nerve refractory period. Such brief bursts of bipolar nsPEF could be the best choice to minimize neuromuscular stimulation in ablation therapies.

CLINICAL EVALUATION OF FUNCTIONAL ELECTRICAL STIMULATION EFFECTIVENESS OF ANTAGONISTIC MUSCLE GROUPS AT WRIST AND ANKLE IN PATIENTS AFTER ISCHEMIC STROKE IN LONG TERM FOLLOW UP

Introduction So far, no detailed evaluation of the results of neuromuscular therapy with functional electrical stimulation combined with kinesiotherapy in long-term observation with clinical methods assessing the scale of post-stroke deficits, muscle strength and the severity of the spasticity symptom on the more paresis side has been performed. Aim The aim of this study was to compare results of neuromuscular functional electrical stimulation algorithm (NMFES) associated with a uniform system of kinesiotherapy based mainly on proprioceptive neuromuscular facilitation (PNF) procedures versus the same system of applied kinesiotherapy alone in home-based treatment of ischemic stroke patients in two months follow up. Material and methods The same set of clinical studies has been applied to a group of 25 healthy volunteers once as well as three times (T0- at hospital ward up to 7 days after an incident, T1- after 21 days of treatment at a hospital ward, T2-after 62 days of home-based treatment) to the 50 patients after ischemic stroke divided into two groups, 25 subjects each (NMFES+K and K groups). Evaluation of treatment effects in two groups of patients was performed with NIHSS scale, Lovett’s scale and Ashworth’s scale. Results After 60 days of applied treatment, only patients of the NMFES+K group represented a statistically significant decrease of NIHSS scale score, indicating the retirement of stroke symptoms. The symptom of increased muscle tension evaluated in the Ashwort’s scale in patients of the NMFES+K group significantly decreased but not in patients of K group. The muscle force of extensor muscles of upper and lower extremities significantly increased only in patients of the NMFES+K group. In general, patients from both groups did not present significant abnormalities in sensory perception within dermatomes C5-C7 and L5-S1 on the more paretic side. Conclusions The proposed personalized, safe and controlled in use a NMFES electrostimulation algorithm gives better, and long-lasting functional effects than previously used as a standard, making it a targeted treatment method. In patients after an ischemic stroke, this treatment reduces post-stroke deficits, increases muscle strength, and reduces the severity of the spasticity symptom on the more paralyzed side. Keywords: ischemic stroke, rehabilitation, functional neuromuscular stimulation, proprioceptive neuromuscular facilitation, clinical evaluation

Effects of Acute Microcurrent Electrical Stimulation on Muscle Function and Subsequent Recovery Strategy.

Microcurrent electrical neuromuscular stimulation (MENS) is believed to alter blood flow, increasing cutaneous blood perfusion, with vasodilation and hyperemia. According to these physiological mechanisms, we investigated the short-term effects of MENS on constant-load exercise and the subsequent recovery process. Ten healthy subjects performed, on separate days, constant-load cycling, which was preceded and followed by active or inactive stimulation to the right quadricep. Blood lactate, pulmonary oxygen, and muscle deoxyhemoglobin on-transition kinetics were recorded. Hemodynamic parameters, heart rate variability, and baroreflex sensitivity were collected and used as a tool to investigate the recovery process. Microcurrent stimulation caused a faster deoxyhemoglobin (4.43 ± 0.5 vs. 5.80 ± 0.5 s) and a slower VO2 (25.19 ± 2.1 vs. 21.94 ± 1.3 s) on-kinetics during cycling, with higher lactate levels immediately after treatments executed before exercise (1.55 ± 0.1 vs. 1.40 ± 0.1 mmol/L) and after exercise (2.15 ± 0.1 vs. 1.79 ± 0.1 mmol/L). In conclusion, MENS applied before exercise produced an increase in oxygen extraction at muscle microvasculature. In contrast, MENS applied after exercise improved recovery, with the sympathovagal balance shifted toward a state of parasympathetic predominance. MENS also caused higher lactate values, which may be due to the magnitude of the muscular stress by both manual treatment and electrical stimulation than control condition in which the muscle received only a manual treatment.

Effect of Submental Surface Neuromuscular Stimulation on Laryngeal Vestibule Opening in Healthy Volunteers at Rest and During Swallowing

Objective: The aim of this study was to determine (a) whether submental electrical stimulation could induce hyolaryngeal movement in healthy adults, (b) the effect of submental surface electrical stimulation on hyolaryngeal movement during stimulated swallows in comparison to nonstimulated swallows, and (c) the effect of submental surface electrical stimulation on vestibular closing both during stimulated swallows and stimulation at rest. Methods: Seven healthy participants with a mean age was 51 ± 5.6 years were included in this study. Each participant received submental neuromuscular electrical stimulation and was given 5 mL of liquid barium to swallow both with and without stimulation. Six randomized trials were recorded—3 with submental surface stimulation and 3 without stimulation with at least one sham stimulation swallow trial at rest. Trials were recorded via videofluoroscopy. Results: A total of 82 trails were recorded. The results of this study indicated (a) there was a hyoid movement as a result of submental stimulation, (b) no laryngeal movement occurred as a result of stimulation, and (c) the vestibule opening size was larger during stimulated swallows as compared with nonstimulated swallows. Conclusion: This study shows that there is increased risk of aspiration with submental stimulation as a result of increased vestibular opening following submental neuromuscular electrical stimulation.

Assessment of the Exposure to Gradient Magnetic Fields Generated by MRI Tomographs: Measurement Method, Verification of Limits and Clearance Areas through a Web-Based Platform.

This work is the result of a campaign of measures of exposure levels to magnetic field gradients (GMF) generated by magnetic resonance imaging (MRI) tomographs, to which both healthcare staff and any persons accompanying patients who remain inside the magnet room are exposed while performing a diagnostic Investigation. The study was conducted on three MRI tomographs with a static magnetic induction field up to 1.5 T installed in two hospitals of Lombardy. The study aims to characterize electromagnetic emissions within the magnet room and the definition of a measurement method suitable for assessing the level of exposure of healthcare personnel and any persons accompanying patients. The measurements performed concerned the determination of the weighted peak index for magnetic induction, due to the diagnostic GMF, relating to the action levels for the workers and the reference levels for the general population, in force in the European Union. Thanks to the defined experimental setup, the use of two different measuring instruments, and the software resources of the WEBNIR platform, it was possible to identify, for both categories of exposed persons, the “clearance” space, i.e., the distance from the magnet of the tomograph that guarantees health protection concerning the exposure to GMF, according to the indications of the standards in force. The method used showed that the exposure levels to GMF are substantially safe for professionally exposed workers who do not carry specific risks. For workers particularly sensitive to the specific risk, as well as to individuals part of the population, it is however advisable to maintain a distance from the magnet of about one meter to prevent sensorial neuromuscular stimulation effects.

A novel intraoral neuromuscular stimulation device for treating sleep-disordered breathing

PurposeTo ascertain the usefulness of a novel intraoral neuromuscular stimulation device in treating patients with primary snoring and mild obstructive sleep apnoea (OSA). This device uses daytime awake neuromuscular electrical stimulation (NMES) as an application to induce toning of the tongue muscles.MethodsA prospective cohort study of 70 patients with sleep-disordered breathing was conducted. Objective snoring and respiratory parameters were recorded with 2 consecutive night WatchPat sleep studies before and after treatment. The device was used for 20 min once daily for a 6-week period. Secondary outcome measures using visual analogue scale reporting of snoring by patient and Epworth Sleepiness Score (ESS) were recorded. Quality of life parameters were also noted.ResultsObjective reduction of snoring was noted on the sleep studies in 95% of participants, with an average snoring time reduction of 48%. Subjectively, the visual analogue scale reported by partners’ similarly demonstrated reduction in 95% of the patients with an average reduction of 40%. In a subset of 38 patients with mild OSA, AHI reduced from 9.8 to 4.7/h (52% reduction), ODI 7.8 to 4.3/h (45% reduction), and ESS from 9.0 to 5.1. Adverse effects encountered were minimal.ConclusionThis prospective cohort study demonstrates a notable improvement in both objective and subjective parameters of snoring and mild OSA in both simple snorers and patients with mild OSA. This device offers a safe and novel approach to reduce snoring and mild OSA by utilising intraoral neuromuscular electrical stimulation. This could be a preferred option for patients as it alleviates the need of using an oral device during sleep.Trial registrationclinicaltrials.gov identifier NCT03829956

The bottom-up approach: Non-invasive peripheral neurostimulation methods to treat migraine: A scoping review from the child neurologist's perspective.

Migraine is a common and invalidating disorder worldwide. Patients of all ages experience the disorder as very impairing regarding their personal and occupational lives. The current approach in migraine therapy is multimodal including lifestyle management, psychoeducation and, if available, psychotherapeutic interventions, and pharmacotherapy. The lack of non-pharmacological and non-invasive treatment options call for new and innovative therapeutic approaches. Peripheral neurostimulation is a relatively new method in migraine management offering a painless and non-pharmacological way of targeting specific mechanisms involved in migraine. This review summarizes 15 recent randomized clinical trials to provide an overview of non-invasive peripheral neurostimulation methods currently available for the treatment of migraine. Efficacy, tolerability, and safety of the different interventions and their feasibility in the pediatric setting are evaluated. Vagal nerve stimulation (VNS), remote electrical neuromodulation (REN) and supraorbital nerve stimulation (SNS) are considered effective in treating acute migraine attacks, the latter being more pronounced in migraine without aura. Regarding migraine prevention, occipital nerve stimulation (ONS) and supraorbital nerve stimulation (SNS) demonstrated efficacy, whereas repetitive neuromuscular magnetic stimulation (rNMS) may represent a further effective option in episodic migraine. REN and rNMS were found to be well-accepted with fewer patients discontinuing treatment than those receiving direct cranial nerve stimulation. In summary, peripheral neurostimulation represents a promising option to complement the multimodal therapy concept for pediatric migraine. In particular, rNMS opens a new field for research and treatment fitting the requirements of "non-invasiveness" for children. Given the reported efficacy, safety, and feasibility, the therapy decision should be made on an individual level.