Special Issue "Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation"

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: 1 July 2021.

Special Issue Editors

Dr. Ursula S. Hofstoetter
E-Mail Website
Guest Editor
Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria
Interests: human spinal locomotor circuits; multiple sclerosis; neural control of movement; neuromodulation; neurorehabilitation; spinal cord; spinal cord injury; spinal cord stimulation
Dr. Karen Minassian
E-Mail Website
Guest Editor
Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria
Interests: catecholaminergic system; central pattern generator; electrophysiology; epidural electrical stimulation; locomotion; neuromodulation; spinal cord physiology; spinal cord injury

Special Issue Information

Dear Colleagues,

Recent research of epidural and transcutaneous electrical spinal cord stimulation has demonstrated unprecedented improvements in motor function thought to be irreversibly lost due to chronic, severe spinal cord injury. Studies in parallel assess these methods for spasticity management as an alternative to medications that are often accompanied by deleterious side effects. As a noninvasive intervention, transcutaneous spinal cord stimulation holds the great potential to find its way into wide clinical application. Its firm establishment and lasting acceptance as clinical practice in spinal cord injury will not only hinge on the demonstration of safety and efficacy, but also on the delineation of a conceptual framework of the underlying physiological mechanisms. This will also require advancing our understanding of immediate and temporary effects of transcutaneous spinal cord on neuronal circuits in the intact and injured spinal cord. The purpose of the present Special Issue is to bring together peers in the field to share—and eventually fuse—their pertinent research into current neurorehabilitation practice by providing a clinical perspective and novel insights into the underlying mechanisms.

Dr. Ursula S. Hofstoetter
Dr. Karen Minassian
Guest Editors

Manuscript Submission Information

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Keywords

  • Human
  • Locomotion
  • Neuromodulation
  • Neurorehabilitation
  • Non-invasive
  • Spasticity
  • Spinal cord circuits
  • Spinal cord injury
  • Spinal reflexes
  • Transcutaneous spinal cord stimulation

Published Papers (5 papers)

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Research

Article
Combined Transcutaneous Spinal Stimulation and Locomotor Training to Improve Walking Function and Reduce Spasticity in Subacute Spinal Cord Injury: A Randomized Study of Clinical Feasibility and Efficacy
J. Clin. Med. 2021, 10(6), 1167; https://doi.org/10.3390/jcm10061167 - 11 Mar 2021
Viewed by 602
Abstract
Locomotor training (LT) is intended to improve walking function and can also reduce spasticity in motor-incomplete spinal cord injury (MISCI). Transcutaneous spinal stimulation (TSS) also influences these outcomes. We assessed feasibility and preliminary efficacy of combined LT + TSS during inpatient rehabilitation in [...] Read more.
Locomotor training (LT) is intended to improve walking function and can also reduce spasticity in motor-incomplete spinal cord injury (MISCI). Transcutaneous spinal stimulation (TSS) also influences these outcomes. We assessed feasibility and preliminary efficacy of combined LT + TSS during inpatient rehabilitation in a randomized, sham-controlled, pragmatic study. Eighteen individuals with subacute MISCI (2–6 months post-SCI) were enrolled and randomly assigned to the LT + TSS or the LT + TSSsham intervention group. Participants completed a 4-week program consisting of a 2-week wash-in period (LT only) then a 2-week intervention period (LT + TSS or LT + TSSsham). Before and after each 2-week period, walking (10 m walk test, 2-min walk test, step length asymmetry) and spasticity (pendulum test, clonus drop test, modified spinal cord injury—spasticity evaluation tool) were assessed. Sixteen participants completed the study. Both groups improved in walking speed and distance. While there were no significant between-groups differences, the LT + TSS group had significant improvements in walking outcomes following the intervention period; conversely, improvements in the LT + TSSsham group were not significant. Neither group had significant changes in spasticity, and the large amount of variability in spasticity may have obscured ability to observe change in these measures. TSS is a feasible adjunct to LT in the subacute stage of SCI and may have potential to augment training-related improvements in walking outcomes. Full article
(This article belongs to the Special Issue Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation)
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Article
Cervical Electrical Neuromodulation Effectively Enhances Hand Motor Output in Healthy Subjects by Engaging a Use-Dependent Intervention
J. Clin. Med. 2021, 10(2), 195; https://doi.org/10.3390/jcm10020195 - 07 Jan 2021
Viewed by 705
Abstract
Electrical enabling motor control (eEmc) through transcutaneous spinal cord stimulation is a non-invasive method that can modify the functional state of the sensory-motor system. We hypothesize that eEmc delivery, together with hand training, improves hand function in healthy subjects more than either intervention [...] Read more.
Electrical enabling motor control (eEmc) through transcutaneous spinal cord stimulation is a non-invasive method that can modify the functional state of the sensory-motor system. We hypothesize that eEmc delivery, together with hand training, improves hand function in healthy subjects more than either intervention alone by inducing plastic changes at spinal and cortical levels. Ten voluntary participants were included in the following three interventions: (i) hand grip training, (ii) eEmc, and (iii) eEmc with hand training. Functional evaluation included the box and blocks test (BBT) and hand grip maximum voluntary contraction (MVC), spinal and cortical motor evoked potential (sMEP and cMEP), and resting motor thresholds (RMT), short interval intracortical inhibition (SICI), and F wave in the abductor pollicis brevis muscle. eEmc combined with hand training retained MVC and increased F wave amplitude and persistency, reduced cortical RMT and facilitated cMEP amplitude. In contrast, eEmc alone only increased F wave amplitude, whereas hand training alone reduced MVC and increased cortical RMT and SICI. In conclusion, eEmc combined with hand grip training enhanced hand motor output and induced plastic changes at spinal and cortical level in healthy subjects when compared to either intervention alone. These data suggest that electrical neuromodulation changes spinal and, perhaps, supraspinal networks to a more malleable state, while a concomitant use-dependent mechanism drives these networks to a higher functional state. Full article
(This article belongs to the Special Issue Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation)
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Article
Immediate Effects of Transcutaneous Spinal Cord Stimulation on Motor Function in Chronic, Sensorimotor Incomplete Spinal Cord Injury
J. Clin. Med. 2020, 9(11), 3541; https://doi.org/10.3390/jcm9113541 - 02 Nov 2020
Cited by 1 | Viewed by 728
Abstract
Deficient ankle control after incomplete spinal cord injury (iSCI) often accentuates walking impairments. Transcutaneous electrical spinal cord stimulation (tSCS) has been shown to augment locomotor activity after iSCI, presumably due to modulation of spinal excitability. However, the effects of possible excitability modulations induced [...] Read more.
Deficient ankle control after incomplete spinal cord injury (iSCI) often accentuates walking impairments. Transcutaneous electrical spinal cord stimulation (tSCS) has been shown to augment locomotor activity after iSCI, presumably due to modulation of spinal excitability. However, the effects of possible excitability modulations induced by tSCS on ankle control have not yet been assessed. This study investigated the immediate (i.e., without training) effects during single-sessions of tonic tSCS on ankle control, spinal excitability, and locomotion in ten individuals with chronic, sensorimotor iSCI (American Spinal Injury Association Impairment Scale D). Participants performed rhythmic ankle movements (dorsi- and plantar flexion) at a given rate, and irregular ankle movements following a predetermined trajectory with and without tonic tSCS at 15 Hz, 30 Hz, and 50 Hz. In a subgroup of eight participants, the effects of tSCS on assisted over-ground walking were studied. Furthermore, the activity of a polysynaptic spinal reflex, associated with spinal locomotor networks, was investigated to study the effect of the stimulation on the dedicated spinal circuitry associated with locomotor function. Tonic tSCS at 30 Hz immediately improved maximum dorsiflexion by +4.6° ± 0.9° in the more affected lower limb during the rhythmic ankle movement task, resulting in an increase of +2.9° ± 0.9° in active range of motion. Coordination of ankle movements, assessed by the ability to perform rhythmic ankle movements at a given target rate and to perform irregular movements according to a trajectory, was unchanged during stimulation. tSCS at 30 Hz modulated spinal reflex activity, reflected by a significant suppression of pathological activity specific to SCI in the assessed polysynaptic spinal reflex. During walking, there was no statistical group effect of tSCS. In the subgroup of eight assessed participants, the three with the lowest as well as the one with the highest walking function scores showed positive stimulation effects, including increased maximum walking speed, or more continuous and faster stepping at a self-selected speed. Future studies need to investigate if multiple applications and individual optimization of the stimulation parameters can increase the effects of tSCS, and if the technique can improve the outcome of locomotor rehabilitation after iSCI. Full article
(This article belongs to the Special Issue Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation)
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Article
Transcutaneous Spinal Cord Stimulation Enhances Quadriceps Motor Evoked Potential in Healthy Participants: A Double-Blind Randomized Controlled Study
J. Clin. Med. 2020, 9(10), 3275; https://doi.org/10.3390/jcm9103275 - 13 Oct 2020
Viewed by 602
Abstract
Transcutaneous electrical spinal cord stimulation (tSCS) is a non-invasive technique for neuromodulation and has therapeutic potential for motor rehabilitation following spinal cord injury. The main aim of the present study is to quantify the effect of a single session of tSCS on lower [...] Read more.
Transcutaneous electrical spinal cord stimulation (tSCS) is a non-invasive technique for neuromodulation and has therapeutic potential for motor rehabilitation following spinal cord injury. The main aim of the present study is to quantify the effect of a single session of tSCS on lower limb motor evoked potentials (MEPs) in healthy participants. A double-blind, sham-controlled, randomized, crossover, clinical trial was carried out in 15 participants. Two 10-min sessions of tSCS (active-tSCS and sham-tSCS) were applied at the T11-T12 vertebral level. Quadriceps (Q) and tibialis anterior (TA) muscle MEPs were recorded at baseline, during and after tSCS. Q and TA isometric maximal voluntary contraction was also recorded. A significant increase of the Q-MEP amplitude was observed during active-tSCS (1.96 ± 0.3 mV) when compared from baseline (1.40 ± 0.2 mV; p = 0.01) and when compared to sham-tSCS at the same time-point (1.13 ± 0.3 mV; p = 0.03). No significant modulation was identified for TA-MEP amplitude or for Q and TA isometric maximal voluntary isometric strength. In conclusion, tSCS applied over the T11-T12 vertebral level increased Q-MEP but not TA-MEP compared to sham stimulation. The specific neuromodulatory effect of tSCS on Q-MEP may reflect optimal excitation of this motor response at the interneuronal or motoneuronal level. Full article
(This article belongs to the Special Issue Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation)
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Article
The Effects of Adding Transcutaneous Spinal Cord Stimulation (tSCS) to Sit-To-Stand Training in People with Spinal Cord Injury: A Pilot Study
J. Clin. Med. 2020, 9(9), 2765; https://doi.org/10.3390/jcm9092765 - 26 Aug 2020
Cited by 1 | Viewed by 781
Abstract
Spinal cord stimulation may enable recovery of volitional motor control in people with chronic Spinal Cord Injury (SCI). In this study we explored the effects of adding SCS, applied transcutaneously (tSCS) at vertebral levels T10/11, to a sit-to-stand training intervention in people with [...] Read more.
Spinal cord stimulation may enable recovery of volitional motor control in people with chronic Spinal Cord Injury (SCI). In this study we explored the effects of adding SCS, applied transcutaneously (tSCS) at vertebral levels T10/11, to a sit-to-stand training intervention in people with motor complete and incomplete SCI. Nine people with chronic SCI (six motor complete; three motor incomplete) participated in an 8-week intervention, incorporating three training sessions per week. Participants received either tSCS combined with sit-to-stand training (STIM) or sit-to-stand training alone (NON-STIM). Outcome measures were carried out before and after the intervention. Seven participants completed the intervention (STIM N = 5; NON-STIM N = 2). Post training, improvements in International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) motor scores were noted in three STIM participants (range 1.0–7.0), with no change in NON-STIM participants. Recovery of volitional lower limb muscle activity and/or movement (with tSCS off) was noted in three STIM participants. Unassisted standing was not achieved in any participant, although standing with minimal assistance was achieved in one STIM participant. This pilot study has shown that the recruitment of participants, intervention and outcome measures were all feasible in this study design. However, some modifications are recommended for a larger trial. Full article
(This article belongs to the Special Issue Spinal Cord Injury and Transcutaneous Spinal Cord Stimulation)
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Planned Papers

The below list represents only planned manuscripts. Some of these manuscripts have not been received by the Editorial Office yet. Papers submitted to MDPI journals are subject to peer-review.

Combined transcutaneous spinal stimulation and locomotor training for improvement of walking function and reduction of spasticity: a randomized study of efficacy and clinical feasibility

Stephen P. Estes1, Anastasia Zarkou1, Jasmine Hope1,2, Edelle C Field-Fote1,2

[1] Shepherd Center, [2] Emory University School of Medicine

Locomotor training (LT) aims to improve walking function and can reduce spasticity in persons with motor-incomplete spinal cord injury (MISCI). Likewise, transcutaneous spinal stimulation (TSS) has been shown to influence these same outcomes. 

Comparative efficacy of transcutaneous spinal stimulation versus whole body vibration for reducing spasticity in persons with SCI

Kyle Condon1, Evan Sandler1,2, Edelle Field-Fote1,2,3

[1] Shepherd Center, [2] Georgia Institute of Technology, [3] Emory University School of Medicine

In persons with spinal cord injury (SCI), spasticity is a common secondary complication which negatively impacts function and quality of life. Literature indicates antispasmodics have limited value for managing spasticity, prompting interest in non-pharmacological approaches. Both transcutaneous spinal stimulation (TSS) and whole body vibration (WBV) and have been shown to reduce spasticity. We compared immediate, delayed, and persistent single-session effects of TSS and TSS on quadriceps spasticity as measured by the pendulum test. 

Tentative Title: Transcutaneous spinal cord stimulation enhances the Quadriceps Motor Evoked Potentials in healthy subjects. A double-blinded randomized controlled study.

Megía-García A; Serrano-Muñoz D; Taylor J; Avendaño-Coy J; Comino-Suarez N; Gómez-Soriano J.

Tentative Abstract: Introduction: transcutaneous electrical spinal cord stimulation (tSCS) is a non-invasive technique purposed to generate a neuromodulatory effect in the central nervous system. It has demonstrated to be a safe and feasible technique with a great therapeutic potential. The main aim of the present study is to quantify the effect of a single session of tSCS over the motor evoked potentials (MEPs) measured in healthy subjects. 

Tentative Title: Is the Posterior Muscle Root reflex influenced by the body weight load in spinal cord injury subjects?

Authors: Comino-Sánchez N; Megía-García A; del Ama-Espinosa A; Moreno J; Gómez-Soriano J; Gil-Agudo A; Taylor J; Serrano-Muñoz D.

Tentative Abstract: Introduction: posterior root muscle reflex (PRM) is the muscle response evoked by the direct stimulation of large-diameter afferent fibres (Ia, Ib, II) belong to the posterior root in the spinal cord entrance. Previous studies have been demonstrated that PRM can be modulated by active muscle contraction, posture, and others central components. However, it isn´t knowledge of the modulation of PRM threshold suffered by suspension of body weight. This information is essential due to the combination of the spinal stimulation with gait training using body weight support assistance, that is being used in several protocols for gait rehabilitation in spinal cord injury. Aims: To analyse the variations in threshold of PRM due to body weight discharge in spinal cord injury subjects. Moreover, the peak-to-peak amplitude and latencies of PMR will be also analysed with the objective of exploring the modulations in central nervous system due to body weigh suspension.

Tentative Title: Transcutaneous spinal cord stimulation combined with Lokomat for gait rehabilitation of the spinal cord injury

Authors: Comino-Suárez N; Megía-García A; del Ama-Espinosa A; Moreno J; Gómez-Soriano J; Serrano-Muñoz D; Gil-Agudo A; Avendaño-Coy J; Esclarín-de-Ruz A.

Tentative Abstract: Introduction: Locomotion is affected in most of the patients with spinal cord injury. The use of robotic devices for gait recovery enables an early, high intensity and task-specific stepping therapy inducing neuroplastic changes. Recently, as well as epidural spinal cord stimulation, transcutaneous spinal cord stimulation (tSCS) allows for the stimulation of the dorsal root, evoking a reflex at lower limbs known as posterior root-muscle reflex (PRM). Objective: To analyse the feasibility, the safety and the effectiveness of a combined treatment of tSCS and Lokomat for gait rehabilitation in incomplete spinal cord injury patients. 

Characterization of spinal sensorimotor network using transcutaneous spinal stimulation during voluntary movement preparation and performance

Authors:D.A. Atkinson, A.G. Steele, B. Varghese, J. Oh, D.G. Sayenko

Brief Abstract:Transcutaneous electrical spinal cord stimulation (TSS) can be used to differentially activate motor pools based on their anatomical arrangements in the lumbosacral enlargement. These spatial patterns of spinal motor activation may have important clinical implications, especially when there is a need to target specific motor pools. However, our understanding of the net effects and interplay between the motor pools projecting to agonist and antagonist muscles during the preparation and performance of voluntary movements is still limited. The present study was designed to systematically investigate and differentiate the multi-segmental convergence of supraspinal inputs on lumbosacral neural network before and during the execution of voluntary movements in neurologically intact participants.

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