Trial Outcomes & Findings for Epidural Stimulation in Multiple Sclerosis (NCT NCT06019611)
NCT ID: NCT06019611
Last Updated: 2025-04-27
Results Overview
Change in maximum knee flexion, measured in degrees. Difference in maximum knee flexion between Baseline and End of Study with epidural stimulation off, and at End of Study between epidural stimulation off and epidural stimulation on.
COMPLETED
NA
2 participants
Baseline and 4 weeks.
2025-04-27
Participant Flow
Of 2 enrolled participants, 2 met inclusion criteria and proceeded to treatment.
Participant milestones
| Measure |
Percutaneous Epidural Stimulation
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Overall Study
STARTED
|
2
|
|
Overall Study
COMPLETED
|
2
|
|
Overall Study
NOT COMPLETED
|
0
|
Reasons for withdrawal
Withdrawal data not reported
Baseline Characteristics
Epidural Stimulation in Multiple Sclerosis
Baseline characteristics by cohort
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Age, Customized
Age 21 - 40
|
0 Participants
n=99 Participants
|
|
Age, Customized
Age 41+
|
2 Participants
n=99 Participants
|
|
Sex: Female, Male
Female
|
0 Participants
n=99 Participants
|
|
Sex: Female, Male
Male
|
2 Participants
n=99 Participants
|
|
Race (NIH/OMB)
American Indian or Alaska Native
|
0 Participants
n=99 Participants
|
|
Race (NIH/OMB)
Asian
|
0 Participants
n=99 Participants
|
|
Race (NIH/OMB)
Native Hawaiian or Other Pacific Islander
|
0 Participants
n=99 Participants
|
|
Race (NIH/OMB)
Black or African American
|
0 Participants
n=99 Participants
|
|
Race (NIH/OMB)
White
|
2 Participants
n=99 Participants
|
|
Race (NIH/OMB)
More than one race
|
0 Participants
n=99 Participants
|
|
Race (NIH/OMB)
Unknown or Not Reported
|
0 Participants
n=99 Participants
|
PRIMARY outcome
Timeframe: Baseline and 4 weeks.Change in maximum knee flexion, measured in degrees. Difference in maximum knee flexion between Baseline and End of Study with epidural stimulation off, and at End of Study between epidural stimulation off and epidural stimulation on.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Kinematics
Difference in maximum knee flexion between Baseline and End of Study with ES off
|
15.5 degrees
Interval 1.0 to 30.0
|
|
Kinematics
Difference in maximum knee flexion at End of Study between ES off and ES on
|
10 degrees
Interval 4.0 to 16.0
|
PRIMARY outcome
Timeframe: Baseline and 4 weeksPercentage of change in postural sway area (cm\^2) measured based on the center of force trajectory sway in the anterior-posterior and medial-lateral directions during static balance test with eyes-open. Decrease in postural sway area indicates an improvement in balance. Difference in postural sway area during balance test between Baseline and End of Study with epidural stimulation off, and at End of Study between epidural stimulation off and epidural stimulation on, both with subjects' eyes open, and closed.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Static Balance, Eyes-open.
Difference in postural sway area between Baseline (ES off) and End of Study (ES off), eyes open
|
-50 percent change
|
|
Static Balance, Eyes-open.
Difference in postural sway area between Baseline (ES off) and End of Study (ES off), eyes closed
|
-90 percent change
|
|
Static Balance, Eyes-open.
Difference in postural sway area between End of Study (ES off) and End of Study (ES on), eyes open
|
-29 percent change
|
|
Static Balance, Eyes-open.
Difference in postural sway area between End of Study (ES off) and End of Study (ES on), eyes closed
|
-54 percent change
|
PRIMARY outcome
Timeframe: End of Study (4 weeks)Percentage of change in Root Mean Square (RMS) (time averaging, period of 0.25 sec) electromyography (EMG) (normalized to the max value during all gait cycles) of hamstring and rectus femoris during late-stance to mid-swing phase of gait, at End of Study between epidural stimulation on and epidural stimulation off.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Electromyography (EMG)
Change in voltage measurements of rectus femoris at End of Study, between ES on and ES off
|
-7 percent change
Interval -14.0 to 0.0
|
|
Electromyography (EMG)
Change in voltage measurements of hamstring at End of Study, between ES on and ES off
|
20 percent change
Interval 0.0 to 40.0
|
PRIMARY outcome
Timeframe: End of Study (4 weeks)Change in measurements of the first swing angle (FSA) leg muscle tone utilizing Wartenberg's pendulum test, focusing on subject's most impaired side, measured at End of Study between epidural stimulation off and epidural stimulation on.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Spasticity, Knee Extensors (1)
|
6.5 degrees
Interval 5.0 to 8.0
|
PRIMARY outcome
Timeframe: End of Study (4 weeks)Population: 1 participant analyzed per row.
Change in measurement of leg muscle tone utilizing the Modified Ashworth Scale (MAS). The Modified Ashworth Scale (MAS) is the standard clinical assessment tool for evaluating extremity spasticity in patients with central nervous system lesions. In this study, spasticity in the knee extensor muscles was assessed with the participant in a supine position, their legs dangling off the edge of an adjustable-height therapy mat. The resistance to knee flexion was graded on a 0-4 scale (0, 1, 1+, 2, 3, and 4) according to the MAS protocol for knee flexion, with lower scores indicating less muscle tone (0: no increase in muscle tone; 4: limb rigid in flexion). MAS was scored individually for both the right and left sides and reported separately at the end of the study, both with and without epidural stimulation. (A score of 1.5 indicates a MAS score of 1+).
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Spasticity, Knee Extensors (2)
Participant 1, right side, ES off
|
2 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 1, right side, ES on
|
1.5 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 1, left side, ES off
|
2 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 1, left side, ES on
|
0 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 2, right side, ES off
|
1.5 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 2, right side, ES on
|
1.5 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 2, left side, ES off
|
1.5 score on a scale
|
|
Spasticity, Knee Extensors (2)
Participant 2, left side, ES on
|
1 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksChange in walking speed during gait analysis, measured between Baseline and End of Study with epidural stimulation off, and at End of Study between epidural stimulation off and epidural stimulation on.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Overground Ambulation
Change in walking speed during gait analysis, measured between Baseline and End of Study with ES off
|
-25 percent change
Interval -32.0 to -18.0
|
|
Overground Ambulation
Change in walking speed during gait analysis, measured at End of Study between ES off and ES on
|
15 percent change
Interval 6.0 to 25.0
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported disability status, utilizing the Short Form (36) Health Survey (SF-36). Questions are numerically ranked, with lower numbers representing more disability. Scores are combined into a composite scale from 0-100, with a score of zero equivalent to maximum disability and a score of 100 equivalent to no disability.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Disability
Participant 1, Baseline
|
68 score on a scale
|
|
Disability
Participant 1, End of Study
|
72 score on a scale
|
|
Disability
Participant 2, Baseline
|
56 score on a scale
|
|
Disability
Participant 2, End of Study
|
50 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported fatigue status, utilizing the Modified Fatigue Impact Scale (MFIS). Items are scaled so that higher scores indicate a greater impact of fatigue on a person's activities. The total MFIS score can range from 0 to 84, with a score of zero equivalent to no fatigue and a score of 84 equivalent to maximum fatigue.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Fatigue
Participant 1, Baseline
|
30 score on a scale
|
|
Fatigue
Participant 1, End of Study
|
30 score on a scale
|
|
Fatigue
Participant 2, Baseline
|
30 score on a scale
|
|
Fatigue
Participant 2, End of Study
|
34 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported pain status, utilizing the Pain Effects Scale (PES). Items are scaled so that higher scores indicate a greater impact of pain on a person's activities. The total PES score can range from 5 to 30, with a score of 5 equivalent to no pain and a score of 30 equivalent to maximum pain.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Pain, Overall
Participant 1, Baseline
|
17 score on a scale
|
|
Pain, Overall
Participant 1, End of Study
|
18 score on a scale
|
|
Pain, Overall
Participant 2, Baseline
|
19 score on a scale
|
|
Pain, Overall
Participant 2, End of Study
|
16 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported bladder control, utilizing the Bladder Control Scale (BLCS). Items are scaled so that lower scores indicate a greater degree of bladder control. The total BLCS score can range from 0 to 22, with a score of 0 equivalent to complete bladder control and a score of 22 equivalent to very poor bladder control.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Bladder Control
Participant 1, Baseline
|
1 score on a scale
|
|
Bladder Control
Participant 1, End of Study
|
0 score on a scale
|
|
Bladder Control
Participant 2, Baseline
|
2 score on a scale
|
|
Bladder Control
Participant 2, End of Study
|
13 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported bladder control, utilizing the Bowel Control Scale (BWCS). Items are scaled so that lower scores indicate a greater degree of bowel control. The total BWCS score can range from 0 to 26, with a score of 0 equivalent to complete bowel control and a score of 26 equivalent to very poor bowel control.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Bowel Control
Participant 1, Baseline
|
1 score on a scale
|
|
Bowel Control
Participant 1, End of Study
|
0 score on a scale
|
|
Bowel Control
Participant 2, Baseline
|
5 score on a scale
|
|
Bowel Control
Participant 2, End of Study
|
9 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported visual impairment, utilizing the Impact of Visual Impairment Scale (IVIS). Items are scaled so that lower scores indicate less impairment on simple visual tasks. The total IVIS score can range from 0 to 15, with a score of 0 equivalent to no impairment and a score of 15 equivalent to severe visual impairment.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Impact of Visual Impairment
Participant 1, End of Study
|
0 score on a scale
|
|
Impact of Visual Impairment
Participant 1, Baseline
|
3 score on a scale
|
|
Impact of Visual Impairment
Participant 2, Baseline
|
0 score on a scale
|
|
Impact of Visual Impairment
Participant 2, End of Study
|
0 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported cognitive dysfunction, utilizing the Perceived Deficits Questionnaire (PDQ). Items are scaled so that lower scores indicate less cognitive dysfunction. The total PDQ score can range from 0 to 80, with a score of 0 equivalent to no cognitive dysfunction and a score of 80 equivalent to extreme cognitive dysfunction.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Cognitive Dysfunction
Participant 1, Baseline
|
0 score on a scale
|
|
Cognitive Dysfunction
Participant 1, End of Study
|
0 score on a scale
|
|
Cognitive Dysfunction
Participant 2, Baseline
|
2 score on a scale
|
|
Cognitive Dysfunction
Participant 2, End of Study
|
9 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported psychological distress and psychological well-being, utilizing the Mental Health Inventory (MHI-18). Items are scaled so that higher scores indicate less psychological distress. The raw score range is 0-100, with higher scores equivalent to less psychological distress and greater psychological well-being.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Mental Health
Participant 1, Baseline
|
78 score on a scale
|
|
Mental Health
Participant 1, End of Study
|
98 score on a scale
|
|
Mental Health
Participant 2, Baseline
|
73 score on a scale
|
|
Mental Health
Participant 2, End of Study
|
53 score on a scale
|
SECONDARY outcome
Timeframe: Baseline and 4 weeksPopulation: 1 participant analyzed per row.
Measurement of changes in patient-reported availability of social support, utilizing the Modified Social Support Survey (MSSS). Items are scaled so that higher scores indicate more social support. The total MSSS score can range from 18 to 90, with a score of 18 equivalent to no social support and a score of 90 equivalent to strong social support.
Outcome measures
| Measure |
Percutaneous Epidural Stimulation
n=2 Participants
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Social Support
Participant 1, Baseline
|
66 score on a scale
|
|
Social Support
Participant 1, End of Study
|
89 score on a scale
|
|
Social Support
Participant 2, Baseline
|
63 score on a scale
|
|
Social Support
Participant 2, End of Study
|
70 score on a scale
|
Adverse Events
Percutaneous Epidural Stimulation
Serious adverse events
Adverse event data not reported
Other adverse events
| Measure |
Percutaneous Epidural Stimulation
n=2 participants at risk
Epidural spinal stimulation will be delivered via percutaneously implanted electrodes during rehabilitation. All implanted electrodes will be removed at the end of trial participation. The effects of epidural stimulation will be recorded via electrophysiological and biomechanical metrics described within the outcomes measures.
Percutaneous epidural stimulation: Abbott percutaneous trial lead for epidural neurostimulation (Model 3086)
Abbott clinician programmer for epidural and dorsal root ganglion neurostimulation (Model 3874)
Ripple Neuromed Nomad Neurostimulation System
|
|---|---|
|
Injury, poisoning and procedural complications
Skin abrasion
|
50.0%
1/2 • Number of events 2 • 4 weeks.
|
|
Musculoskeletal and connective tissue disorders
Knee pain
|
50.0%
1/2 • Number of events 1 • 4 weeks.
|
|
Renal and urinary disorders
Bladder incontinence
|
50.0%
1/2 • Number of events 1 • 4 weeks.
|
Additional Information
Dr. Kristin Zhao, Director of the Assistive and Restorative Technologies Laboratory
Mayo Clinic
Results disclosure agreements
- Principal investigator is a sponsor employee
- Publication restrictions are in place