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.

Purpose To validate the Physical body experiences questionnaire simplified for active aging (PBE-QAG) with Rasch measurement theory. PBE-QAG measures body awareness during physical activity and includes dimensions of body-mind relationship, body acceptance, and awareness of physical skills and limits. Methods Adults without pain (n=269), with pain (n=61), with mental health conditions (n=200), and with stroke (n=36) were recruited at the Minnesota State Fair, Highland Fest, and in the Brain Body Mind Lab (University of Minnesota) and completed demographic and clinical questionnaires as well as the PBE-QAG. The PBE-QAG has 12 items, with scores ranging between 0 (totally true) to 4 (totally false). A low total score on the PBE-QAG reflects better body awareness. We evaluated item and person fit, targeting, unidimensionality, person separation reliability (PSR), local item dependence (LID), and differential item functioning (DIF) for demographic and clinical characteristics. We compared with Kruskal-Wallis ANOVA the person mean location in four groups: Adults with or without mental health conditions; and whether those groups did body awareness training. Results Unidimensionality and item fit were obtained after deleting 2 and rescoring 5 items. Seven participants did not fit the model (1.23%). There was minimal floor (5.72%), no ceiling effect (0.00%), and no LID. No DIF was greater than 0.50 logits for any of the variables. The Wright-corrected PSR was 0.96. The person mean location was -1.71+/-1.21 logits. Adults with mental health conditions who did not practice body awareness had a higher person mean location [Median (IQR)=0.83(0.89) logits, p<0.0001] versus the other three groups, reflecting lower body awareness. Conclusions PBE-QAG demonstrated good item and person fit, but the targeting is off. Therefore, the current version of PBE-QAG is not recommended for use in the general population. We encourage further validation of PBE-QAG in adults with mental health conditions who do not practice body awareness.

Background About 69% of the 299,000 Americans living with spinal cord injury (SCI) experience long-term debilitating neuropathic pain. New treatments are needed because current treatments do not provide enough pain relief. We have found that insular-opercular brain network alterations may contribute to neuropathic pain and that restoring this network could reduce neuropathic pain. Here, we outline a study protocol using a physical therapy approach, cognitive multisensory rehabilitation (CMR), which has been shown to restore OP1/OP4 connections in adults post stroke, to test our hypothesis that CMR can normalize pain perception through restoring OP1/OP4 connectivity in adults with SCI and relieve neuropathic pain. Objectives To compare baseline brain function via resting-state and task-based functional magnetic resonance imaging in adults with SCI versus uninjured controls, and to identify changes in brain function and behavioral pain outcomes after CMR in adults with SCI. Methods In this phase I randomized controlled trial, adults with SCI will be randomized into two groups: Group A will receive 6 weeks of CMR followed by 6 weeks of standard of care (no therapy) at home. Group B will start with 6 weeks of standard of care (no therapy) at home and then receive 6 weeks of CMR. Neuroimaging and behavioral measures are collected at baseline, after the first 6 weeks (A: post therapy, B: post waitlist), and after the second 6 weeks (A: post-therapy follow-up, B: post therapy), with follow-up of both groups up to 12 months. Conclusion The successful outcome of our study will be a critical next step toward implementing CMR in clinical care to improve health 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.

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