Background: Neuropathic pain after spinal cord injury (SCI) is notoriously hard to treat. Mechanisms of neuropathic pain are unclear, which makes finding effective treatments challenging. Prior studies have shown that adults with SCI have body awareness deficits. Recent imaging studies, including ours, point to the parietal operculum and insula as key areas for both pain perception and body awareness. Cognitive multisensory rehabilitation (CMR) is a physical therapy approach that helps improve body awareness for pain reduction and sensorimotor recovery. Based on our prior brain imaging work in CMR in stroke, we hypothesized that improving body awareness through restoring parietal operculum network connectivity leads to neuropathic pain relief and improved sensorimotor and daily life function in adults with SCI. Thus, the objectives of this study were to (1) determine baseline differences in resting-state and task-based functional magnetic resonance imaging (fMRI) brain function in adults with SCI compared to healthy controls and (2) identify changes in brain function and behavioral pain and pain-associated outcomes in adults with SCI after CMR. Methods: Healthy adults underwent a one-time MRI scan and completed questionnaires. We recruited community-dwelling adults with SCI-related neuropathic pain, with complete or incomplete SCI >3 months, and highest neuropathic pain intensity level of >3 on the Numeric Pain Rating Scale (NPRS). Participants with SCI were randomized into two groups, according to a delayed treatment arm phase I randomized controlled trial (RCT): Group A immediately received CMR intervention, 3x/week, 45 min/session, followed by a 6-week and 1-year follow-up. Group B started with a 6-week observation period, then 6 weeks of CMR, and a 1-year follow-up. Highest, average, and lowest neuropathic pain intensity levels were assessed weekly with the NPRS as primary outcome. Other primary outcomes (fMRI resting-state and functional tasks; sensory and motor function with the INSCI AIS exam), as well as secondary outcomes (mood, function, spasms, and other SCI secondary conditions), were assessed at baseline, after the first and second 6-week period. The INSCI AIS exam and questionnaires were repeated at the 1-year follow-up. Findings: Thirty-six healthy adults and 28 adults with SCI were recruited between September 2020 and August 2021, and 31 healthy adults and 26 adults with SCI were enrolled in the study. All 26 participants with SCI completed the intervention and pre-post assessments. There were no study-related adverse events. Participants were 52+/-15 years of age, and 1-56 years post-SCI. During the observation period, group B did not show any reductions in neuropathic pain and did not have any changes in sensation or motor function (INSCI ASIA exam). However, both groups experienced a significant reduction in neuropathic pain after the 6-week CMR intervention. Their highest level of neuropathic pain of 7.81+/-1.33 on the NPRS at baseline was reduced to 2.88+/-2.92 after 6 weeks of CMR. Their change scores were 4.92+/-2.92 (large effect size Cohen d=1.68) for highest neuropathic pain, 4.12+/-2.23 (d=1.85) for average neuropathic pain, and 2.31+/-2.07 (d=1.00) for lowest neuropathic pain. Nine participants out of 26 were pain-free after the intervention (34.62%). The results of the INSCI AIS testing also showed significant improvements in sensation, muscle strength, and function after 6 weeks of CMR. Their INSCI AIS exam increased by 8.81+/-5.37 points (d=1.64) for touch sensation, 7.50+/-4.89 points (d=1.53) for pin prick sensation, and 3.87+/-2.81 (d=1.38) for lower limb muscle strength. Functional improvements after the intervention included improvements in balance for 17 out of 18 participants with balance problems at baseline; improved transfers for all of them and a returned ability to stand upright with minimal assistance in 12 out of 20 participants who were unable to stand at baseline. Those improvements were maintained at the 1-year follow-up. With regard to brain imaging, we confirmed that the resting-state parietal operculum and insula networks had weaker connections in adults with SCI-related neuropathic pain (n=20) compared to healthy adults (n=28). After CMR, stronger resting-state parietal operculum network connectivity was found in adults with SCI. Also, at baseline, as expected, right toe sensory stimulation elicited less brain activation in adults with SCI (n=22) compared to healthy adults (n=26). However, after CMR, there was increased brain activation in relevant sensorimotor and parietal areas related to pain and mental body representations (i.e., body awareness and visuospatial body maps) during the toe stimulation fMRI task. These brain function improvements aligned with the AIS results of improved touch sensation, including in the feet. Interpretation: Adults with chronic SCI had significant neuropathic pain relief and functional improvements, attributed to the recovery of sensation and movement after CMR. The results indicate the preliminary efficacy of CMR for restoring function in adults with chronic SCI. CMR is easily implementable in current physical therapy practice. These encouraging impressive results pave the way for larger randomized clinical trials aimed at testing the efficacy of CMR to alleviate neuropathic pain in adults with SCI.

Background: About 50% of Americans living with spinal cord injury (SCI) suffer from long-term debilitating neuropathic pain, interfering with quality of daily life. Neuropathic pain is refractory to many available treatments, some carrying a risk for opioid addiction, highlighting an urgent need for new treatments. In this study, we will test our hypothesis that Spring Forest Qigong will reduce SCI-related neuropathic pain by improving body awareness. We will determine whether remotely delivered Qigong is feasible and whether it reduces neuropathic pain (primary outcome). We will also determine whether it reduces spasms frequency and/or severity, improves functional performance, mood, or body awareness (secondary outcomes). Methods: In this quasi-experimental study, adults with SCI will practice Qigong at home with a 45min video, at least 3x/week for 12 weeks. The Qigong practice includes movements with guided breathing and is individualized based on functional abilities, i.e., the participants will do kinesthetic imagery of Qigong movements with guided breathing, for movements that they are unable to perform actively. The primary clinical outcome, i.e., the highest, average, and lowest neuropathic pain ratings perceived in the prior week, will be recorded weekly throughout the study period. The secondary outcomes will be collected at 4 time points: at baseline, midway during the Qigong intervention (6 weeks), after the Qigong intervention (12 weeks), and after the 6-week follow-up. The data will be analyzed with a repeated measure ANOVA and with Tukey post-hoc tests. Discussion: Successful outcomes will provide promising evidence for remotely delivered Qigong for neuropathic pain and spasm reduction in individuals living with SCI.

Introduction. The relationship of HbA1c versus the mean blood glucose (MBG) is an important guide for diabetes management but may differ between ethnic groups. In Africa, the patient’s glucose information is limited or unavailable and the management is largely guided by HbA1c. We sought to determine if the reference data derived from the non-African populations led to an appropriate estimation of MBG from HbA1c for the East African patients. Methods. We examined the relationship of HbA1c versus MBG obtained by the continuous glucose monitoring in a group of East African youth having type 1 diabetes in Kenya and Uganda (n = 54) compared with the data obtained from A1c-derived average glucose (ADAG) and glucose management indicator (GMI) studies. A self-identified White (European heritage) population of youth (n = 89) with type 1 diabetes, 3–18 years old, living in New Orleans, LA, USA metropolitan area (NOLA), was studied using CGM as an additional reference. Results. The regression equation for the African cohort was MBG (mg/dL) = 32.0 + 16.73 × HbA1c (%), r = 0.55, p < 0.0001 . In general, the use of the non-African references considerably overestimated MBG from HbA1c for the East African population. For example, an HbA1c = 9% (74.9 mmol/mol) corresponded to an MBG = 183 mg/dL (10.1 mmol/L) in the East African group, but 212 mg/dL (11.7 mmol/L) using ADAG, 237 mg/dL (13.1 mmol/L) using GMI and 249 mg/dL (13.8 mmol/L) using NOLA reference. The reported occurrence of serious hypoglycemia among the African patients in the year prior to the study was 21%. A reference table of HbA1c versus MBG from the East African patients was generated. Conclusions. The use of non-African-derived reference data to estimate MBG from HbA1c generally led to the overestimation of MBG in the East African patients. This may put the East African and other African patients at higher risk for hypoglycemia when the management is primarily based on achieving target HbA1c in the absence of the corresponding glucose data.

Background: Chronic low back pain (cLBP) affects the quality of life of 52 million Americans and leads to an enormous personal and economic burden. A multidisciplinary approach to cLBP management is recommended. Since medication has limited efficacy and there are mounting concerns about opioid addiction, the American College of Physicians and American Pain Society recommend non-pharmacological interventions, such as mind and body approaches (e.g., Qigong, yoga, Tai Chi) before prescribing medications. Of those, Qigong practice might be most accessible given its gentle movements and because it can be performed standing, sitting, or lying down. The three available Qigong studies in adults with cLBP showed that Qigong reduced pain more than waitlist and equally well than exercise. Yet, the duration and/or frequency of Qigong practice were low (<12 weeks or less than 3x/week). The objectives of this study were to investigate the feasibility of practicing Spring Forest Qigong or performing P.Volve low intensity exercises 3x/week for 12 weeks, feasibility of recruitment, data collection, delivery of the intervention as intended, as well as identify estimates of efficacy on brain function and behavioral outcomes after Qigong practice or exercise. To our knowledge, this is the first study investigating the feasibility of the potential effect of Qigong on brain function in adults with cLBP. Methods: We conducted a feasibility Phase I Randomized Clinical Trial. Of the 36 adults with cLBP recruited between January 2020 and June 2021, 32 were enrolled and randomized to either 12 weeks of remote Spring Forest Qigong practice or remote P.Volve low-intensity exercises. Participants practiced at least 3x/week for 41min/session with online videos. Our main outcome measures were the Numeric Pain Rating Scale (highest, average, and lowest cLBP pain intensity levels in the prior week), assessed weekly and fMRI data (resting-state and task-based fMRI tasks: pain imagery, kinesthetic imagery of a Qigong movement, and robot-guided shape discrimination). We compared baseline resting-state connectivity and brain activation during fMRI tasks in adults with cLBP with data from a healthy control group (n=28) acquired in a prior study. Secondary outcomes included measures of function, disability, body awareness, kinesiophobia, balance, self-efficacy, core muscle strength, and ankle proprioceptive acuity with a custom-build device. Results: Feasibility of the study design and methods was demonstrated with 30 participants completing the study (94% retention) and reporting high satisfaction with the programs; 96% adherence to P.Volve low-intensity exercises, and 128% of the required practice intensity for Spring Forest Qigong practice. Both groups saw promising reductions in low back pain (effect sizes Cohen d=1.01-2.22) and in most other outcomes (d=0.90-2.33). Markers of ankle proprioception were not significantly elevated in the cLBP group after the interventions. Brain imaging analysis showed weaker parietal operculum and insula network connectivity in adults with cLBP (n=26), compared to data from a healthy control group (n=28). The pain imagery task elicited lower brain activation of insula, parietal operculum, angular gyrus and supramarginal gyrus at baseline in adults with cLBP than in healthy adults. Adults with cLBP had lower precentral gyrus activation than healthy adults for the Qigong movement and robot task at baseline. Pre-post brain function changes showed individual variability: Six (out of 13) participants in the Qigong group showed increased activation in the parietal operculum, angular gyrus, supramarginal gyrus, and precentral gyrus during the Qigong fMRI task. Interpretation: Our data indicate the feasibility and acceptability of using Spring Forest Qigong practice or P.Volve low-intensity exercises for cLBP relief showing promising results in terms of pain relief and associated symptoms. Our brain imaging results indicated brain function improvements after 12 weeks of Qigong practice in some participants, pointing to the need for further investigation in larger studies.

Importance: The manuscript proposes the feasibility and potential of a remote Qigong intervention to reduce neuropathic pain in adults with spinal cord injury (SCI)-related neuropathic pain. Objective: We determined the feasibility and estimates of efficacy of a remotely delivered Qigong intervention in adults with SCI-related neuropathic pain. Design: This is a non-randomized controlled trial with outcomes assessed at baseline-, 6- and 12-weeks of Qigong practice, and at 6-weeks and 1-year follow-up. Setting: Completely remote clinical trial. Participants: Adults with SCI-related neuropathic pain, with SCI of at least 3 months, with complete or incomplete SCI, and highest neuropathic pain level of >3 on the Numeric Pain Rating Scale (NPRS). We used nationwide volunteer sampling. We recruited 23 adults with chronic SCI (7/2021-2/2022). Eighteen participants started the study and completed all study components, including the 6-week follow-up. Twelve participants completed the 1-year follow-up assessment. Intervention: Participants practiced the Spring Forest Qigong Five Element Healing Movements with an online video by combining movement with kinesthetic imagery, at least 3x/week for 12 weeks. Main Outcome(s) and Measure(s): To address the feasibility outcome and track adherence, the website automatically monitored the days and duration that the Qigong video was played. Self-report neuropathic pain intensity and SCI-related symptoms such as spasms, functional performance, mood, and body appreciation were also collected. Results: Eighteen participants, 60+/-12 years of age, 15+/-11 years post-SCI had a highest baseline neuropathic pain of 7.94+/-2.33 on the NPRS, which was reduced to 4.17+/-3.07 after 12 weeks of Qigong practice (Cohen d=1.75). This pain relief remained at 6-week and 1-year follow-ups. Participants reported reduced spasm frequency (change score 1.17+/-1.20, d=0.98) and severity (0.72+/-1.02, d=0.71), and reduced interference of neuropathic pain on mood (3.44+/-2.53, d=1.36), sleep (3.39+/-2.40, d=1.41), and daily activities (3.17+/-2.77, d=1.14). They had a greater ability to perform functional activities (Patient Specific Functional Scale, 6.68+/-3.07, d=2.18) and had improved mood (Patient Health Questionnaire-9, 2.33+/-3.31, d=0.70). Conclusions and Relevance: Our preliminary data demonstrate the feasibility of Qigong practice in adults with SCI-related neuropathic pain and promising results of neuropathic pain relief and improvement in SCI-related symptoms after Qigong practice.