Publications by authors named "Scott Bickel"

67 Publications

Effects of functional electrical stimulation on muscle health after spinal cord injury.

Curr Opin Pharmacol 2021 Aug 28;60:226-231. Epub 2021 Aug 28.

Department of Physical Therapy, Samford University, Birmingham, AL, USA. Electronic address:

Spinal cord injury is a devastating condition interrupting voluntary movement and motor control. In response to unloading, skeletal muscle undergoes numerous adaptations, including rapid and profound atrophy, intramuscular fat accumulation, impaired muscular glucose metabolism and decreased force generation and muscle performance. Functional electrical stimulation (FES) involves electrically stimulating affected muscles to contract in a coordinated manner to create a functional movement or task. Effects of FES-cycling, rowing and resistance training on muscle health are described here. Briefly, FES-cycling and resistance training may slow muscle atrophy or facilitate muscle hypertrophy, and all modalities benefit muscle composition and performance to some extent. These interventions show promise as future rehabilitative tools after spinal cord injury.
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http://dx.doi.org/10.1016/j.coph.2021.07.025DOI Listing
August 2021

Influence of muscle fatigue on contractile twitch characteristics in persons with parkinson's disease and older adults: A pilot study.

Clin Park Relat Disord 2021 8;5:100103. Epub 2021 Aug 8.

Dept of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham 1720 2 Ave South, Birmingham, AL 35294, USA.

Introduction: It is widely accepted that pathophysiological changes to the central nervous system of persons with Parkinson's disease (PD) result in negative effects on motor function. However, less information is known regarding the pathology of PD on skeletal muscle. The purpose of this study was to determine the effect of a fatiguing isometric knee extension protocol on muscle mechanics using evoked twitch contractions in persons with PD and in non-impaired older adults (OLD).

Methods: Evoked twitch contractions were examined during a fatiguing protocol in PD (66 ± 9 yr, n = 8) and OLD (65 ± 10 yr, n = 5). Participants performed 5-sec maximal isometric voluntary contractions of the quadriceps femoris with 5-sec rest for 3-min. Every 30-sec during rest intervals, a maximal transcutaneous electrical stimulus was administered to the quadriceps femoris to quantify evoked peak twitch torque (pTT), peak relaxation rate (pRR), and peak rate of torque development (pRTD).

Results: A large effect of voluntary fatigue (%decline) was observed ( = 1.58). There were no significant differences in pTT (p = 0.09; 95% CI:-3.6, 0.28) or pRR (p = 0.11; 95% CI:-31, 3.6). However, the slope decline of pRTD in OLD (-35.4 ± 24.7) was greater than PD (-11.5 ± 11.4; p = 0.03), indicating that skeletal muscle in persons with PD is less fatigable compared to non-impaired older adults.

Conclusion: The rate, not the maximum capacity, of torque generation of the muscle during a fatiguing knee extension protocol was affected by PD. Future studies are warranted to identify the mechanism(s) responsible for the observed differences in skeletal muscle contractile characteristics and potential myofiber distribution variation in PD.
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http://dx.doi.org/10.1016/j.prdoa.2021.100103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8374465PMC
August 2021

Capacity Building for a New Multicenter Network Within the ECHO IDeA States Pediatric Clinical Trials Network.

Front Pediatr 2021 14;9:679516. Epub 2021 Jul 14.

Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States.

Research capacity building is a critical component of professional development for pediatrician scientists, yet this process has been elusive in the literature. The ECHO IDeA States Pediatric Clinical Trials Network (ISPCTN) seeks to implement pediatric trials across medically underserved and rural populations. A key component of achieving this objective is building pediatric research capacity, including enhancement of infrastructure and faculty development. This article presents findings from a site assessment inventory completed during the initial year of the ISPCTN. An assessment inventory was developed for surveying ISPCTN sites. The inventory captured site-level activities designed to increase clinical trial research capacity for pediatrician scientists and team members. The inventory findings were utilized by the ISPCTN Data Coordinating and Operations Center to construct training modules covering 3 broad domains: Faculty/coordinator development; Infrastructure; Trials/Research concept development. Key lessons learned reveal substantial participation in the training modules, the importance of an inventory to guide the development of trainings, and recognizing local barriers to clinical trials research. Research networks that seek to implement successfully completed trials need to build capacity across and within the sites engaged. Our findings indicate that building research capacity is a multi-faceted endeavor, but likely necessary for sustainability of a unique network addressing high impact pediatric health problems. The ISPCTN emphasis on building and enhancing site capacity, including pediatrician scientists and team members, is critical to successful trial implementation/completion and the production of findings that enhance the lives of children and families.
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http://dx.doi.org/10.3389/fped.2021.679516DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316720PMC
July 2021

Pulmonary Function Testing in the Coronavirus Disease Era: Lessons and Opportunities.

Pediatr Allergy Immunol Pulmonol 2021 06;34(2):43-45

Division of Pediatric Pulmonology, Allergy and Immunology, Norton Children's and University of Louisville School of Medicine, Louisville, Kentucky, USA.

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http://dx.doi.org/10.1089/ped.2021.0059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8329726PMC
June 2021

COVID-19 Vaccination Outcomes at a Pediatric Long-Term Care Facility.

Pediatr Infect Dis J 2021 07;40(7):e281-e283

Division of Pediatric Pulmonology, Allergy & Immunology, Norton Children's and University of Louisville School of Medicine, Louisville, KY.

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http://dx.doi.org/10.1097/INF.0000000000003185DOI Listing
July 2021

Impact of Payor-Initiated Switching of Inhaled Corticosteroids on Lung Function.

J Pediatr 2021 Jul 10;234:128-133.e1. Epub 2021 Mar 10.

Division of Pediatric Pulmonology, Norton Children's and University of Louisville School of Medicine, Louisville, KY.

Objectives: To evaluate the impact of a payor-initiated formulary change in inhaled corticosteroid coverage on lung function in patients with asthma and on provider prescribing practices. This formulary change, undertaken in August 2016 by a Medicaid payor in Kentucky, eliminated coverage of beclomethasone dipropionate, a metered dose inhaler (MDI), in favor of mometasone furoate, available as MDI and dry powder inhaler (DPI).

Study Design: A retrospective chart review was conducted on children with asthma ages 6-18 years covered by the relevant payor from a university-based pediatric practice who were seen before the formulary change (February to July 2016) and after (February to July 2017). Spirometry data from each visit was compared using the paired Student t test.

Results: Fifty-eight patients were identified who were initially on beclomethasone dipropionate and had spirometry available at both visits. Those who switched from an MDI to a DPI (n = 24) saw a decline in median predicted forced expiratory volume in 1 second from 98.5% to 91% (P = .013). A decline was also seen in forced expiratory flow at 25%-75%, from 89.5% predicted to 76% predicted (P = .041). No significant changes were observed in children remaining on an MDI. Seven patients discontinued inhaled corticosteroid therapy.

Conclusions: This study suggests insurance formulary changes leading to use of a different inhaler device may have a detrimental impact on pediatric lung function, which may be a surrogate measure for overall asthma control. This could be due to a lack of adequate timely educational intervention as well as the inability of some children to use DPIs.
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http://dx.doi.org/10.1016/j.jpeds.2021.03.008DOI Listing
July 2021

Impact of Activity-Based Therapy on Respiratory Outcomes in a Medically Complex Child.

Children (Basel) 2021 Jan 9;8(1). Epub 2021 Jan 9.

Department of Neurological Surgery, University of Louisville, Louisville, KY 40202, USA.

Introduction: Activity-based therapies (ABTs) focus on activating the neuromuscular system below the level of spinal cord injury (SCI) promoting neuromuscular capacity.

Case Description: A 2 year 7 month old with history of prematurity at 29 weeks, neonatal epidural abscess, resultant cervical SCI, respiratory failure, and global developmental delays presented for enrollment in an outpatient activity-based therapy program. Upon presentation to this program, he required nighttime mechanical ventilation via tracheostomy and daytime suctioning. He could not perform any age-appropriate activities and was described by his mother as 'present', neither engaged nor attentive. During and after 7 months of participation in ABTs including locomotor training and neuromuscular electrical stimulation, the patient demonstrated unexpected changes in his respiratory status leading to ventilator weaning with concomitant improvements in head and trunk control, participation, development, and quality of life.

Discussion: ABT was not only safe for a medically complex child, but also this intervention had a remarkable effect on unresolved respiratory capacity and a more widespread impact on other functions as well as development. A child with a chronic, severe SCI demonstrated positive and impactful improvements in health, functional status, and quality of life during an episode of ABT.
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http://dx.doi.org/10.3390/children8010036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827889PMC
January 2021

Single and sequential voluntary cough in children with chronic spinal cord injury.

Respir Physiol Neurobiol 2021 03 24;285:103604. Epub 2020 Dec 24.

Department of Neurological Surgery, University of Louisville, 220 Abraham Flexner Way 15(th) floor, Louisville, KY, 40202, United States. Electronic address:

We investigated the impact of spinal cord injury (SCI) on cough capacity in 10 children (Mean ± SD, age 8 ± 4 years) and compared it to 15 typically developing children (age 8 ± 3 years). Participants underwent spirometry, single and sequential cough assessment with surface-electromyography from respiratory muscles. Inspiratory phase duration, inspiratory phase peak flow, inspiratory phase rise time, compression phase duration, expiratory phase rise time, expiratory phase peak airflow (EPPF) and cough volume acceleration (CVA) parameters of single and sequential cough were measured. Root mean square (RMS) values of right pectoralis-major, intercostal, rectus-abdominus (RA), and oblique (OB) muscles were calculated and mean of three trials were compared. The significance criterion was set at P < 0.05. The SCI group produced significantly lower lung volumes, EPPF, CVA, and RMS values of RA and OB during expiratory phases of single and sequential coughs. The decrease in activation in expiratory muscles in the SCI group accounts for the impaired expiratory flow and may contribute to risk of respiratory complications.
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http://dx.doi.org/10.1016/j.resp.2020.103604DOI Listing
March 2021

Obesity-related asthma in children: A role for vitamin D.

Pediatr Pulmonol 2021 02 8;56(2):354-361. Epub 2020 Dec 8.

Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.

Excess adipose tissue predisposes to an enhanced inflammatory state and can contribute to the pathogenesis and severity of asthma. Vitamin D has anti-inflammatory properties and low-serum levels are seen in children with asthma and in children with obesity. Here we review the intersection of asthma, obesity, and hypovitaminosis D in children. Supplementation with vitamin D has been proposed as a simple, safe, and inexpensive adjunctive therapy in a number of disease states. However, little research has examined the pharmacokinetics of vitamin D and its therapeutic potential in children who suffer from obesity-related asthma.
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http://dx.doi.org/10.1002/ppul.25053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8341445PMC
February 2021

Child Neurology: Triosephosphate isomerase deficiency.

Neurology 2020 12 1;95(24):e3448-e3451. Epub 2020 Sep 1.

From the Divisions of Pediatric Hospitalist Medicine (C.H., H.H.), Pediatric Neurology (D.F.), Pediatric Pulmonology (S.B., R.M.), and Pediatric Genetics (A.A.), University of Louisville School of Medicine (B.N.), KY.

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http://dx.doi.org/10.1212/WNL.0000000000010745DOI Listing
December 2020

Spinal cord injury in infancy: activity-based therapy impact on health, function, and quality of life in chronic injury.

Spinal Cord Ser Cases 2020 03 10;6(1):13. Epub 2020 Mar 10.

Kosair Charities Center for Pediatric NeuroRecovery, University of Louisville, Louisville, KY, USA.

Introduction: Spinal cord injury (SCI) in infancy magnifies the complexity of a devastating diagnosis. Children injured so young have high incidences of scoliosis, hip dysplasia, and respiratory complications leading to poor health and outcomes. We report the medical history, progression of rehabilitation, usual care and activity-based therapy, and outcomes for a child injured in infancy. Activity-based therapy (ABT) aims to activate the neuromuscular system above and below the lesion through daily, task-specific training to improve the neuromuscular capacity, and outcomes for children with acquired SCI.

Case Presentation: A 3-month-old infant suffered a cervical SCI from a surgical complication with resultant tetraplegia. Until age 3, her medical complications included scoliosis, kyphosis, and pneumonia. Even with extensive physical and occupational therapy, she was fully dependent on caregivers for mobility and unable to roll, come to sit, sit, stand or walk. She initiated ABT at ~3 years old, participating for 8 months. The child's overall neuromuscular capacity improved significantly, especially for head and trunk control, contributing to major advances in respiratory health, novel engagement with her environment, and improved physical abilities.

Discussion: From injury during infancy until 3 years old, this child's health, abilities, and complications were consistent with the predicted path of early-onset SCI. Due to her age at injury, severity and chronicity of injury, she demonstrated unexpected, meaningful changes in her neuromuscular capacity during and post-ABT associated with improved health, function and quality of life for herself and her caregivers.
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http://dx.doi.org/10.1038/s41394-020-0261-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7064539PMC
March 2020

Multi-Level Factors Associated with Social Participation among Stroke Survivors: China's Health and Retirement Longitudinal Study (2011-2015).

Int J Environ Res Public Health 2019 12 15;16(24). Epub 2019 Dec 15.

Department of Physical Therapy, Samford University School of Health Professions, CHS Building 2 2159, 800 Lakeshore Drive, Birmingham, AL 35229, USA.

Background: This study aims to examine the impact of individual-level and community-based factors on popular social participation activities of Chinese middle-aged and older adults post-stroke.

Methods: Sub-samples of survivors of stroke (2011: n = 413, 2013: n = 395, 2015: n = 441) recruited by the China Health and Retirement Longitudinal Study (CHARLS) were included in the analysis. Zero-inflated Poisson and multi-level logistic regression models were used to explore factors associated with social participation.

Results: More than half of individuals (55.0%) had no social participation and 23.4% participated in multiple social activities. The most popular social activities that individuals participated in were interacting with friends (32.6%) and going to a community club to play table games (22.7%). Multiple individual-level factors were negatively related to social participation (e.g., depressive symptoms and multiple measures of functional limitations) while the allocation of an outdoor exercise facility in the community/village was positively associated with the participation of going to a community club to play table games.

Conclusion: Stroke survivors are at high risk of limited social participation. Policymakers and other key stakeholders should consider community design among other potential solutions when identifying ways to link at-risk stroke survivors to both opportunities for rehabilitation (e.g., physical function) and social participation.
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http://dx.doi.org/10.3390/ijerph16245121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6950688PMC
December 2019

The impact of varying interphase interval on neuromuscular electrical stimulation-induced quadriceps femoris muscle performance and perceived discomfort.

Physiother Theory Pract 2021 Oct 31;37(10):1117-1125. Epub 2019 Oct 31.

Department of Physical Therapy, Samford University, School of Health Professions, Birmingham, AL, USA.

Determine the effects of varying frequency, phase duration, and interphase interval (IPI) of symmetrical, biphasic pulsed current (SBPC) on quadriceps femoris muscle torque production, perceived discomfort, and muscle fatigue when using neuromuscular electrical stimulation (NMES). Ten recreationally active able-bodied participants completed this study. Muscle torque was measured during a series of laboratory based, NMES-induced muscle contractions with varying combinations of phase durations (50, 100, 150, or 200 µs) and IPIs (50, 100, 150, or 200 µs) at 25 and 50 Hz. A three-factorial repeated measures experimental design was used. After each contraction, participants rated perceived discomfort on a 10-cm visual analog scale. Subsequently, fatigue tests were conducted using different frequency-IPI combinations. Results of within-subjects ANOVAs revealed no interaction among the three factors: frequency, phase duration and IPI. Significant main effects of phase duration and IPI, but not frequency, on torque production and perceived discomfort were observed. Specifically, significant linear and quadratic trends were observed for the effect of phase duration and IPI on torque production, and the effect of IPI on discomfort, and only a significant linear trend for the effect of phase duration on discomfort. The shorter IPI combined with the longer phase duration produced greater torque with tolerable discomfort. There was no significant effect of IPI on muscle fatigue. Study findings indicated that when administering SBPC on the quadriceps femoris muscle, clinicians should select an IPI of 50 µs and a longer phase duration (e.g. 200 µs) to maximize torque without imposing intolerable discomfort.
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http://dx.doi.org/10.1080/09593985.2019.1685032DOI Listing
October 2021

Effects of High-Intensity Interval Training Versus Moderate-Intensity Training on Cardiometabolic Health Markers in Individuals With Spinal Cord Injury: A Pilot Study.

Top Spinal Cord Inj Rehabil 2019 16;25(3):248-259. Epub 2019 May 16.

Department of Human Studies, University of Alabama at Birmingham, Birmingham, Alabama.

Recent studies in nondisabled individuals have demonstrated that low-volume high-intensity interval training (HIIT) can improve cardiometabolic health similar to moderate-intensity training (MIT) despite requiring 20% of the overall time commitment. To date, there have been no studies assessing the effects of HIIT for improving cardiometabolic health in individuals with SCI. The primary purpose of this pilot study was to compare the effects of 6 weeks of low-volume HIIT vs MIT using arm crank ergometer exercise to improve body composition, cardiovascular fitness, glucose tolerance, blood lipids, and blood pressure in a cohort of individuals with longstanding SCI. Participants were randomized to 6 weeks of HIIT or MIT arm crank exercise training. Aerobic capacity, muscular strength, blood lipids, glucose tolerance, blood pressure, and body composition were assessed at baseline and 6 weeks post training. Seven individuals (6 male, 1 female; = 3 in MIT and = 4 in HIIT; mean age 51.3 ± 10.5 years) with longstanding SCI completed the study. The preliminary findings from this pilot study demonstrated that individuals with SCI randomized to either 6 weeks of HIIT or MIT displayed improvements in (a) insulin sensitivity, (b) cardiovascular fitness, and (c) muscular strength ( < .05). However, MIT led to greater improvements in arm fat percent and chest press strength compared to HIIT ( < .05). No differences between MIT and HIIT were observed. Both conditions led to improvements in insulin sensitivity, aerobic capacity, muscle strength, and blood lipids in individuals with SCI. Future larger cohort studies are needed to determine if the shorter amount of time required from HIIT is preferable to current MIT exercise recommendations.
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http://dx.doi.org/10.1310/sci19-00042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743747PMC
January 2020

Characteristics of Adults With Neurologic Disability Recruited for Exercise Trials: A Secondary Analysis.

Adapt Phys Activ Q 2018 Oct 1;35(4):476-497. Epub 2018 Nov 1.

1 University of Alabama at Birmingham/Lakeshore Research Collaborative.

This review examined demographic and clinical characteristics of participants from exercise trials in 3 neurologic disability conditions (multiple sclerosis, spinal cord injury, and traumatic brain injury) and compared these data with population-based statistics. The authors included 75 published studies from 2006 to 2016: 53 studies for multiple sclerosis (n = 2,034), 14 for spinal cord injury (n = 302), and 8 for traumatic brain injury (n = 272). Pooled data resembled some heterogeneous aspects of population data sets. However, many characteristics were not reported; samples were small and predominantly White, and 48.1% of the people screened were excluded. Thus, findings from these studies may not be translatable across the range of people with these three conditions, which warrant efforts to target the inclusion of underrepresented subgroups in future exercise trials.
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http://dx.doi.org/10.1123/apaq.2017-0109DOI Listing
October 2018

A high-protein diet or combination exercise training to improve metabolic health in individuals with long-standing spinal cord injury: a pilot randomized study.

Physiol Rep 2018 08;6(16):e13813

Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, Alabama.

We compared the effects of an 8-week iso-caloric high-protein (HP) diet versus a combined exercise regimen (Comb-Ex) in individuals with long-standing spinal cord injury (SCI). Effects on metabolic profiles, markers of inflammation, and signaling proteins associated with glucose transporter 4 (GLUT-4) translocation in muscles were evaluated. Eleven participants with SCI completed the study (HP diet: n = 5; Comb-Ex: n = 6; 46 ± 8 years; C5-T12 levels; American Spinal Injury Association Impairment Scale A or B). The Comb-Ex regimen included upper body resistance training (RT) and neuromuscular electrical stimulation-induced-RT for paralytic quadriceps muscles, interspersed with high-intensity (80-90% VO peak) arm cranking exercises 3 days/week. The HP diet included ~30% total energy as protein (carbohydrate to protein ratio <1.5, ~30% energy from fat). Oral glucose tolerance tests and muscle biopsies of the vastus lateralis (VL) and deltoid muscles were performed before and after the trial. Fasting plasma glucose levels decreased in the Comb-Ex (P < 0.05) group compared to the HP-diet group. A decrease in areas under the curve for insulin and TNF-α concentrations was observed for all participants regardless of group assignment (time effect, P < 0.05). Although both groups exhibited a quantitative increase in insulin sensitivity as measured by the Matsuda Index, the change was clinically meaningful only in the HP diet group (HP diet: pre, 4.6; post, 11.6 vs. Comb-Ex: pre, 3.3; post, 4.6). No changes were observed in proteins associated with GLUT-4 translocation in VL or deltoid muscles. Our results suggest that the HP-diet and Comb-Ex regimen may improve insulin sensitivity and decrease TNF-α concentrations in individuals with SCI.
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http://dx.doi.org/10.14814/phy2.13813DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113133PMC
August 2018

Exploring the uptake and implementation of tele-monitored home-exercise programmes in adults with Parkinson's disease: A mixed-methods pilot study.

J Telemed Telecare 2020 Jan-Feb;26(1-2):53-63. Epub 2018 Aug 22.

Electrical & Computer Engineering University of Alabama at Birmingham, USA.

Background: People with Parkinson's disease experience numerous barriers to exercise participation at fitness facilities. Advances in tele-monitoring technologies create alternative channels for managing and supervising exercise programmes in the home. However, the success of these programmes will depend on participants' perceptions of using the technology and their exercise adherence. Thus, this pilot explored the uptake and implementation of two common methods of Internet-exercise training in Parkinson's disease.

Methods: Twenty adults with Parkinson's disease were randomized into either: telecoach-assisted exercise (TAE) or self-regulated exercise (SRE) groups. Both groups received the same eight-week exercise prescription (combined strength and aerobic exercise) and telehealth system that streamed and recorded vital signs and exercise data. TAE participants exercised under a telecoach's supervision via videoconferencing. SRE participants independently managed their exercise training. Quantitative data were described and qualitative data underwent thematic analysis.

Results: Quantitative results demonstrated that TAE participants achieved strong attendance (99.2%), whereas SRE participants demonstrated 35.9% lower attendance, 48% less total time exercising, and 74.5% less time exercising at moderate intensity. Qualitatively, TAE participants reported overtly favourable programme experiences and that assistance from a telecoach enhanced their exercise motivation. SRE participants noted several challenges that impeded adherence.

Conclusion: Findings demonstrate that adults with Parkinson's disease acknowledge benefits of exercising through a telehealth system and are open to utilizing this channel as a means of exercise. However, human-interactive support may be required to overcome unique impediments to participation. Study findings warrant validation in larger trials that can transfer the success of TAE towards more scalable methods of delivery.
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http://dx.doi.org/10.1177/1357633X18794315DOI Listing
June 2020

Paralytic and nonparalytic muscle adaptations to exercise training versus high-protein diet in individuals with long-standing spinal cord injury.

J Appl Physiol (1985) 2018 07 1;125(1):64-72. Epub 2018 Mar 1.

Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham , Birmingham, Alabama.

This study compares the effects of an 8-wk isocaloric high-protein (HP) diet versus a combination exercise (Comb-Ex) regimen on paralytic vastus lateralis (VL) and nonparalytic deltoid muscle in individuals with long-standing spinal cord injury (SCI). Fiber-type distribution, cross-sectional area (CSA), levels of translation initiation signaling proteins (Erk-1/2, Akt, p70S6K1, 4EBP1, RPS6, and FAK), and lean thigh mass were analyzed at baseline and after the 8-wk interventions. A total of 11 participants (C5-T12 levels, 21.8 ± 6.3 yr postinjury; 6 Comb-Ex and 5 HP diet) completed the study. Comb-Ex training occurred 3 days/wk and consisted of upper body resistance training (RT) in addition to neuromuscular electrical stimulation (NMES)-induced-RT for paralytic VL muscle. Strength training was combined with high-intensity arm-cranking exercises (1-min intervals at 85-90%, V̇o) for improving cardiovascular endurance. For the HP diet intervention, protein and fat each comprised 30%, and carbohydrate comprised 40% of total energy. Clinical tests and muscle biopsies were performed 24 h before and after the last exercise or diet session. The Comb-Ex intervention increased Type IIa myofiber distribution and CSA in VL muscle and Type I and IIa myofiber CSA in deltoid muscle. In addition, Comb-Ex increased lean thigh mass, V̇o, and upper body strength ( P < 0.05). These results suggest that exercise training is required to promote favorable changes in paralytic and nonparalytic muscles in individuals with long-standing SCI, and adequate dietary protein consumption alone may not be sufficient to ameliorate debilitating effects of paralysis. NEW & NOTEWORTHY This study is the first to directly compare the effects of an isocaloric high-protein diet and combination exercise training on clinical and molecular changes in paralytic and nonparalytic muscles of individuals with long-standing spinal cord injury. Our results demonstrated that muscle growth and fiber-type alterations can best be achieved when the paralyzed muscle is sufficiently loaded via neuromuscular electrical stimulation-induced resistance training.
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http://dx.doi.org/10.1152/japplphysiol.01029.2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6086973PMC
July 2018

Human neuromuscular aging: Sex differences revealed at the myocellular level.

Exp Gerontol 2018 06 24;106:116-124. Epub 2018 Feb 24.

Geriatric Research, Education, and Clinical Center, VA Medical Center, Birmingham, AL, 35233, United States; UAB Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States; Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL 35294, United States; Division of Geriatrics, Gerontology, and Palliative Care, University of Alabama at Birmingham, Birmingham, AL 35294, United States. Electronic address:

Age-related muscle loss (sarcopenia) is a major clinical problem affecting both men and women - accompanied by muscle weakness, dysfunction, disability, and impaired quality of life. Current definitions of sarcopenia do not fully encompass the age-related changes in skeletal muscle. We therefore examined the influence of aging and sex on elements of skeletal muscle health using a thorough histopathological analysis of myocellular aging and assessments of neuromuscular performance. Two-hundred and twenty-one untrained males and females were separated into four age cohorts [mean age 25 y (n = 47), 37 y (n = 79), 61 y (n = 51), and 72 y (n = 44)]. Total (-12%), leg (-17%), and arm (-21%) lean mass were lower in both 61 y and 72 y than in 25 y or 37 y (P < 0.05). Knee extensor strength (-34%) and power (-43%) were lower (P < 0.05) in the older two groups, and explosive sit-to-stand power was lower by 37 y (P < 0.05). At the histological/myocellular level, type IIx atrophy was noted by 37 y and type IIa atrophy by 61 y (P < 0.05). These effects were driven by females, noted by substantial and progressive type IIa and IIx atrophy across age. Aged female muscle displayed greater within-type myofiber size heterogeneity and marked type I myofiber grouping (~5-fold greater) compared to males. These findings suggest the predominant mechanisms leading to whole muscle atrophy differ between aging males and females: myofiber atrophy in females vs. myofiber loss in males. Future studies will be important to better understand the mechanisms underlying sex differences in myocellular aging and optimize exercise prescriptions and adjunctive treatments to mitigate or reverse age-related changes.
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http://dx.doi.org/10.1016/j.exger.2018.02.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6031257PMC
June 2018

Sustainability of exercise intervention outcomes among people with disabilities: a secondary review.

Disabil Rehabil 2019 06 6;41(13):1584-1595. Epub 2018 Feb 6.

e Department of Physical Therapy, School of Health Professions , University of Alabama at Birmingham , Birmingham , AL , USA.

Background: This review explored the sustainability of health and physical activity-based outcomes following exercise trials that were conducted for people with disabilities, and characterised the influence of technology and behaviour change strategies.

Methods: A total of 132 studies were screened from an existing database.

Results: Only 22 studies featured follow-up periods and met eligibility criteria. At follow-up, studies typically reported at least one significant health outcome that was maintained (n = 18/21; 86%). However, significant health outcomes accounted for only 32% of the total volume of outcomes that were measured at follow-up. For physical activity-based outcomes, six studies (n = 6/8; 75%) reported that intervention gains were maintained throughout follow-up. The incorporation of technology or behaviour change strategies appeared to be linked with sustainable intervention effects.

Conclusions: Overall, some evidence demonstrated that post-intervention effects were sustainable. However, the strength of the evidence was weak and several existing gaps in knowledge were identified. Moreover, most studies did not focus on sustainability, but instead emphasised short-term effects of exercise participation on health and physical activity outcomes. Study findings call for greater research and programme efforts to maintain health, function, and physical activity behaviour after supports provided by research studies are removed. Implications for rehabilitation Short-term exercise programmes may require additional strategies designed specifically to enhance the sustainability of exercise outcomes and physical activity participation. Incorporating technology within exercise interventions may enhance the likelihood of sustaining health and function outcomes. Exercise programmes framed within behaviour change theory can equip individuals with the appropriate strategies necessary to maintain their physical activity participation.
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http://dx.doi.org/10.1080/09638288.2018.1432704DOI Listing
June 2019

Effects of aging and Parkinson's disease on motor unit remodeling: influence of resistance exercise training.

J Appl Physiol (1985) 2018 04 21;124(4):888-898. Epub 2017 Dec 21.

Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham , Birmingham, Alabama.

Aging muscle atrophy is in part a neurodegenerative process revealed by denervation/reinnervation events leading to motor unit remodeling (i.e., myofiber type grouping). However, this process and its physiological relevance are poorly understood, as is the wide-ranging heterogeneity among aging humans. Here, we attempted to address 1) the relation between myofiber type grouping and molecular regulators of neuromuscular junction (NMJ) stability; 2) the impact of motor unit remodeling on recruitment during submaximal contractions; 3) the prevalence and impact of motor unit remodeling in Parkinson's disease (PD), an age-related neurodegenerative disease; and 4) the influence of resistance exercise training (RT) on regulators of motor unit remodeling. We compared type I myofiber grouping, molecular regulators of NMJ stability, and the relative motor unit activation (MUA) requirement during a submaximal sit-to-stand task among untrained but otherwise healthy young (YA; 26 yr, n = 27) and older (OA; 66 yr, n = 91) adults and OA with PD (PD; 67 yr, n = 19). We tested the effects of RT on these outcomes in OA and PD. PD displayed more motor unit remodeling, alterations in NMJ stability regulation, and a higher relative MUA requirement than OA, suggesting PD-specific effects. The molecular and physiological outcomes tracked with the severity of type I myofiber grouping. Together these findings suggest that age-related motor unit remodeling, manifested by type I myofiber grouping, 1) reduces MUA efficiency to meet submaximal contraction demand, 2) is associated with disruptions in NMJ stability, 3) is further impacted by PD, and 4) may be improved by RT in severe cases. NEW & NOTEWORTHY Because the physiological consequences of varying amounts of myofiber type grouping are unknown, the current study aims to characterize the molecular and physiological correlates of motor unit remodeling. Furthermore, because exercise training has demonstrated neuromuscular benefits in aged humans and improved innervation status and neuromuscular junction integrity in animals, we provide an exploratory analysis of the effects of high-intensity resistance training on markers of neuromuscular degeneration in both Parkinson's disease (PD) and age-matched older adults.
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http://dx.doi.org/10.1152/japplphysiol.00563.2017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5972459PMC
April 2018

High-Intensity Exercise Acutely Increases Substantia Nigra and Prefrontal Brain Activity in Parkinson's Disease.

Med Sci Monit 2017 Dec 23;23:6064-6071. Epub 2017 Dec 23.

UAB Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.

BACKGROUND Pathologic alterations in resting-state brain activity patterns exist among individuals with Parkinson's disease (PD). Since physical exercise alters resting-state brain activity in non-PD populations and improves PD symptoms, we assessed the acute effect of exercise on resting-state brain activity in exercise-trained individuals with PD. MATERIAL AND METHODS Resting-state functional magnetic resonance imaging (fMRI) was collected twice for 17 PD participants at the conclusion of an exercise intervention. The acute effect of exercise was examined for PD participants using the amplitude of low frequency fluctuation (ALFF) before and after a single bout of exercise. Correlations of clinical variables (i.e., PDQ-39 quality of life and MDS-UPDRS) with ALFF values were examined for the exercise-trained PD participants. RESULTS An effect of acute exercise was observed as an increased ALFF signal within the right ventromedial prefrontal cortex (PFC), left ventrolateral PFC, and bilaterally within the substantia nigra (SN). Quality of life was positively correlated with ALFF values within the vmPFC and vlPFC. CONCLUSIONS Given the role of the SN and PFC in motor and non-motor symptoms in PD, the acute increases in brain activity within these regions, if repeated frequently over time (i.e., exercise training), may serve as a potential mechanism underlying exercise-induced PD-specific clinical benefits.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5747933PMC
http://dx.doi.org/10.12659/msm.906179DOI Listing
December 2017

Racial Differences in Weight Gain: A 5-Year Longitudinal Study of Persons With Spinal Cord Injury.

Arch Phys Med Rehabil 2018 10 14;99(10):1957-1964. Epub 2017 Dec 14.

Shirley Ryan Ability Lab, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Objective: To assess racial differences in body mass index (BMI) change over 5 years among people with spinal cord injury (SCI).

Design: Multicenter longitudinal study.

Setting: Spinal Cord Injury Model Systems centers.

Participants: Individuals (N=437; 313 non-Hispanic white, 81 non-Hispanic black, and 43 Hispanic; 335 men; mean age, 41.3±13.5y) who incurred an SCI from 1974 to 2010 and completed 2 follow-up assessments within 5 years between October 1, 2006 and September 18, 2015 (mean duration of injury, 9.1±9.6y at the start of the 5-year follow-up).

Interventions: Not applicable.

Main Outcome Measures: BMI (in kilograms per meters squared).

Results: The mean BMI of 437 participants increased from 26.4±6.3 to 27.0±6.4kg/m over 5 years (P=.002). The greatest increase was noted for Hispanics (2.0±5.7kg/m; P=.02), followed by non-Hispanic whites (0.6±3.9kg/m; P=.01) and non-Hispanic blacks (0.01±3.7kg/m; P>.99). The differences in BMI increase across racial groups were significant (P=.03) in those with paraplegia (American Spinal Injury Association Impairment Scale A, B or C), those who were underweight or of normal weight at baseline, and those within 10 years of their injury. Such racial differences remained significant after taking into account demographic and injury characteristics.

Conclusions: Our study findings provide a foundation for future research to explore risk and protective factors that contribute to racial differences in weight gain after SCI, which help alert health care professionals to a high-risk group for obesity prevention and management.
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http://dx.doi.org/10.1016/j.apmr.2017.11.005DOI Listing
October 2018

Randomized, four-arm, dose-response clinical trial to optimize resistance exercise training for older adults with age-related muscle atrophy.

Exp Gerontol 2017 12 28;99:98-109. Epub 2017 Sep 28.

UAB Center for Exercise Medicine, University of Alabama at Birmingham, Birmingham, AL 35294, United States; Department of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, AL 35294, United States; Geriatric Research, Education, and Clinical Center, Veterans' Affairs Medical Center, Birmingham, AL 35233, United States. Electronic address:

Purpose: The myriad consequences of age-related muscle atrophy include reduced muscular strength, power, and mobility; increased risk of falls, disability, and metabolic disease; and compromised immune function. At its root, aging muscle atrophy results from a loss of myofibers and atrophy of the remaining type II myofibers. The purpose of this trial (NCT02442479) was to titrate the dose of resistance training (RT) in older adults in an effort to maximize muscle regrowth and gains in muscle function.

Methods: A randomized, four-arm efficacy trial in which four, distinct exercise prescriptions varying in intensity, frequency, and contraction mode/rate were evaluated: (1) high-resistance concentric-eccentric training (H) 3d/week (HHH); (2) H training 2d/week (HH); (3) 3d/week mixed model consisting of H training 2d/week separated by 1 bout of low-resistance, high-velocity, concentric only (L) training (HLH); and (4) 2d/week mixed model consisting of H training 1d/week and L training 1d/week (HL). Sixty-four randomized subjects (65.5±3.6y) completed the trial. All participants completed the same 4weeks of pre-training consisting of 3d/week followed by 30weeks of randomized RT.

Results: The HLH prescription maximized gains in thigh muscle mass (TMM, primary outcome) and total body lean mass. HLH also showed the greatest gains in knee extension maximum isometric strength, and reduced cardiorespiratory demand during steady-state walking. HHH was the only prescription that led to increased muscle expression of pro-inflammatory cytokine receptors and this was associated with a lesser gain in TMM and total body lean mass compared to HLH. The HL prescription induced minimal muscle regrowth and generally lesser gains in muscle performance vs. the other prescriptions.

Major Conclusions: The HLH prescription offers distinct advantages over the other doses, while the HL program is subpar. Although limited by a relatively small sample size, we conclude from this randomized dose-response trial that older adults benefit greatly from 2d/week high-intensity RT, and may further benefit from inserting an additional weekly bout of low-load, explosive RT.

Trial Registration: ClinicalTrials.govNCT02442479.
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http://dx.doi.org/10.1016/j.exger.2017.09.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5765758PMC
December 2017

Teleexercise for Persons With Spinal Cord Injury: A Mixed-Methods Feasibility Case Series.

JMIR Rehabil Assist Technol 2016 Jul 14;3(2):e8. Epub 2016 Jul 14.

School of Health Professions, University of Alabama at Birmingham, Birmingham, AL, United States.

Background: Spinal cord injury (SCI) results in significant loss of function below the level of injury, often leading to restricted participation in community exercise programs. To overcome commonly experienced barriers to these programs, innovations in technology hold promise for remotely delivering safe and effective bouts of exercise in the home.

Objective: To test the feasibility of a remotely delivered home exercise program for individuals with SCI as determined by (1) implementation of the intervention in the home; (2) exploration of the potential intervention effects on aerobic fitness, physical activity behavior, and subjective well-being; and (3) acceptability of the program through participant self-report.

Methods: Four adults with SCI (mean age 43.5 [SD 5.3] years; 3 males, 1 female; postinjury 25.8 [SD 4.3] years) completed a mixed-methods sequential design with two phases: an 8-week intervention followed by a 3-week nonintervention period. The intervention was a remotely delivered aerobic exercise training program (30-45 minutes, 3 times per week). Instrumentation included an upper body ergometer, tablet, physiological monitor, and custom application that delivered video feed to a remote trainer and monitored and recorded exercise data in real time. Implementation outcomes included adherence, rescheduled sessions, minutes of moderate exercise, and successful recording of exercise data. Pre/post-outcomes included aerobic capacity (VO peak), the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD), the Satisfaction with Life Scale (SWLS), and the Quality of Life Index modified for spinal cord injury (QLI-SCI). Acceptability was determined by participant perceptions of the program features and impact, assessed via qualitative interview at the end of the nonintervention phase.

Results: Participants completed all 24 intervention sessions with 100% adherence. Out of 96 scheduled training sessions for the four participants, only 8 (8%) were makeup sessions. The teleexercise system successfully recorded 85% of all exercise data. The exercise program was well tolerated by all participants. All participants described positive outcomes as a result of the intervention and stated that teleexercise circumvented commonly reported barriers to exercise participation. There were no reported adverse events and no dropouts.

Conclusion: A teleexercise system can be a safe and feasible option to deliver home-based exercise for persons with SCI. Participants responded favorably to the intervention and valued teleexercise for its ability to overcome common barriers to exercise. Study results are promising but warrant further investigation in a larger sample.
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http://dx.doi.org/10.2196/rehab.5524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454561PMC
July 2016

Quantification and characterization of grouped type I myofibers in human aging.

Muscle Nerve 2018 Jan 7;57(1):E52-E59. Epub 2017 Sep 7.

Departments of Cell, Developmental, and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Introduction: Myofiber type grouping is a histological hallmark of age-related motor unit remodeling. Despite the accepted concept that denervation-reinnervation events lead to myofiber type grouping, the completeness of those conversions remains unknown.

Methods: Type I myofiber grouping was assessed in vastus lateralis biopsies from Young (26 ± 4 years; n = 27) and Older (66 ± 4 years; n = 91) adults. Grouped and ungrouped type I myofibers were evaluated for phenotypic differences.

Results: Higher type I grouping in Older versus Young was driven by more myofibers per group (i.e., larger group size) (P < 0.05). In Older only, grouped type I myofibers displayed larger cross-sectional area, more myonuclei, lower capillary supply, and more sarco(endo)plasmic reticulum calcium ATPase I (SERCA I) expression (P < 0.05) than ungrouped type I myofibers.

Discussion: Grouped type I myofibers retain type II characteristics suggesting that conversion during denervation-reinnervation events is either progressive or incomplete. Muscle Nerve 57: E52-E59, 2018.
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http://dx.doi.org/10.1002/mus.25711DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711619PMC
January 2018

Current Trends in Exercise Intervention Research, Technology, and Behavioral Change Strategies for People With Disabilities: A Scoping Review.

Am J Phys Med Rehabil 2017 Oct;96(10):748-761

From the University of Alabama at Birmingham/Lakeshore Research Collaborative, Birmingham, Alabama (BL, H-JY, RWM, JHR); and Department of Physical Therapy, Samford University, Birmingham, Alabama (CSB).

This review synthesized physical activity and exercise intervention literature for the past 10 yrs for people with physical and cognitive disabilities including intervention characteristics, behavior change strategies, and types of technologies used to improve targeted outcomes. Systematic searches yielded 132 eligible studies. The major disability groups were multiple sclerosis (41%), stroke (15%), and spinal cord injury (12%). Research designs primarily involved randomized controlled trials (61%) versus quasi-experimental designs (39%). Approximately 20% of the interventions used some form of the following technology: information and communication technology (48%), interactive technology (37%), or electronic gauges (30%). Eighteen percent of studies used intervention strategies based on behavioral theory, which was typically combined with technology to promote activity and increase adherence in generally larger study samples. The three prevailing theories included social cognitive theory (58%), supportive accountability theory (21%), and transtheoretical model (21%). Upon completing the intervention, studies reported primarily significant outcomes (80%). Exercise research for PWD has grown in both quantity and quality, but several gaps remain. Study findings provide a roadmap for future exercise trials on understudied populations and highlight technology and behavior change theory as drivers of future intervention research.
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http://dx.doi.org/10.1097/PHM.0000000000000743DOI Listing
October 2017

Elderly Woman With Painful Swollen Fingers.

Ann Emerg Med 2017 Mar;69(3):297-314

Department of Emergency Medicine, Maricopa Medical Center, and Samaritan Regional Poison Control Center, Phoenix, AZ.

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http://dx.doi.org/10.1016/j.annemergmed.2016.09.027DOI Listing
March 2017

Unusual Mucus Impaction in an Adolescent Patient With Severe Asthma.

Clin Pediatr (Phila) 2017 12 13;56(14):1361-1364. Epub 2017 Jan 13.

1 University of Louisville, Louisville, KY, USA.

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http://dx.doi.org/10.1177/0009922816685818DOI Listing
December 2017
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