Search Results (48)

Background/Objectives: Cardiovascular (CV) dysfunction and, specifically, orthostatic hypotension, may significantly impact the quality of life of individuals with spinal cord injuries (SCIs) at T6 or above. While spinal cord transcutaneous stimulation (scTS) has shown immediate effects on blood pressure regulation, its long-term effects remain largely unexplored. Methods: This case study examines the sustained effects of scTS on blood pressure regulation and orthostatic tolerance in a 33-year-old female with cervical (C4) complete SCI sustained two years earlier. This individual underwent an initial baseline tilt test without stimulation, completed six 30 min scTS-CV sessions (cardiovascular-focused stimulation) over two weeks as the “training” phase, and then had repeated tilt tests without stimulation posttraining. Results: Following training, the participant demonstrated an improvement in orthostatic tolerance, maintaining a 70° tilt for 30 min, compared to only 3 min at baseline, in a tilt test (without stimulation) conducted one day posttraining. Self-reported reduction in orthostatic burden and decreased midodrine dependence were also observed for several weeks, with improvements diminishing by 6 weeks posttraining. Conclusions: These observations suggest that brief, repeated scTS-CV sessions may lead to sustained improvements in orthostatic tolerance beyond the immediate period of stimulation. Although the duration of these effects has yet to be established, this approach could offer a non-invasive alternative for managing CV dysfunction in SCIs. Full article

Refractory neuropathic pain of the head and neck remains a major clinical challenge, particularly when mediated through the cervicotrigeminal complex (CTC), a unique anatomical hub integrating trigeminal and upper cervical nociceptive inputs. This narrative review synthesizes neuroanatomical, pathophysiological, and clinical evidence to provide a unifying framework for diagnosis and management. A structured search of PubMed, Scopus, and Web of Science identified English-language clinical and mechanistic studies addressing CTC-mediated pain, with case reports excluded unless mechanistically informative. We propose multidimensional refractoriness criteria that integrate pharmacological non-response, failed interventional strategies, and objective functional impairment. Current treatments span pharmacotherapy, peripheral interventions (nerve blocks, radiofrequency ablation), and neuromodulation at multiple network levels (occipital nerve stimulation, spinal cord stimulation, motor cortex stimulation, deep brain stimulation). Non-invasive approaches such as rTMS, tDCS, and vagus nerve stimulation are emerging but remain investigational. Advances in imaging and neurophysiological biomarkers now permit greater precision in detecting CTC dysfunction and tailoring therapy. By combining anatomical precision, mechanistic insight, and multidisciplinary strategies, this review proposes a clinically actionable definition of refractoriness and supports a stepwise, mechanism-based approach to therapy. CTC emerges as a targetable hub for diagnostic and therapeutic strategies in refractory head and neck pain. Full article

Background/Objectives: Respiratory impairment is the leading cause of morbidity and mortality in participants with spinal cord injury (SCI). Cervical SCI (cSCI) severely compromises respiratory function due to paralysis and weakness of the respiratory muscles. Recent evidence suggests that transcutaneous electrical spinal cord stimulation (tSCS) may enhance motor strength and promote functional recovery. Therefore, cervical tSCS, applied at cervical segments, holds potential as a therapeutic strategy to improve respiratory function in participants with cervical SCI. Methods: This randomized controlled trial with a partial crossover design included participants with both complete and incomplete cSCI. Neurological assessments were used, as well as tests to evaluate pulmonary function maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), and spirometric measurements. These assessments were conducted at baseline and after the last session. The experimental group received tSCS at the C3–C4 and C6–C7 cervical spinal levels, delivered at a frequency of 30 Hz during occupational therapy. The control group underwent identical occupational therapy sessions without stimulation. Each session lasted 30 min and was conducted over eight days. Results: Fifteen participants with cSCI received tSCS, while 11 cSCI participants were included in the control group. Seven participants took part in both groups. Only the tSCS group showed significant improvements in MIP, MEP, and forced vital capacity (p < 0.05), while no significant changes were observed in the control group. Conclusions: tSCS applied at the cervical segments can promote respiratory function following cervical SCI. This approach may support neuroplasticity and help reduce long-term respiratory complications in participants with cervical SCI. However, to confirm these effects, long-term stimulation protocols and follow-up studies in larger SCI populations are required. Full article

Given the cervical spinal cord’s role in locomotor and rhythmic upper limb tasks, its neuromodulation has emerged as an important area of study for understanding human spinal rhythmogenesis. We previously demonstrated that, under unloading conditions, arm muscle vibrostimulation can elicit non-voluntary upper limb oscillations. In this study, we investigated the effects of transcranial magnetic stimulation (TMS) of the motor cortex during both voluntary and non-voluntary (vibration-induced) rhythmic arm movements. We analyzed motor-evoked potentials, mean arm muscle activity, and kinematic parameters of arm movements, including cycle duration and shoulder and elbow joint angular oscillations. Motor-evoked potentials in proximal arm muscles were significantly modulated during both movement types. Notably, low-frequency TMS markedly enhanced non-voluntary arm oscillations, whereas its effect on voluntary movements was statistically non-significant. This differential response is likely due to the absence of characteristic supraspinal influences in sensory-induced spinal activation during non-voluntary movements. These findings align with previous evidence showing that supraspinal pathways facilitate rhythmogenesis in the lower limbs, and they now extend this concept to the upper limbs. Overall, our results suggest that therapies aimed at modulating cervical central pattern generators may benefit from the active engagement of supraspinal motor circuits. Full article

This paper presents a wearable, open-source system that combines electromyography (EMG) and functional electrical stimulation (FES) to restore hand function in individuals with disabilities caused by cervical spinal cord injuries or stroke. The device captures electrical signals produced during volitional muscle contractions and analyzes them to interpret the user’s intent to move. This information is then used to stimulate impaired muscles, promoting improved hand function and rehabilitation. We detail the design, prototyping, and testing of the system, emphasizing its modularity, affordability, and accessibility. Hardware and software, along with 3D-printable components, are shared via GitHub to enable replication and customization by professionals and makers. The system serves as both an orthotic device for enhancing grasping ability and a therapeutic tool for rehabilitating hemiparetic hands, with potential for broader applications. By addressing cost, customization, and accessibility barriers, this initiative promotes collaboration and further innovation in rehabilitation technologies, advancing the development of affordable, user-centered solutions for individuals with disabilities. Full article

The ability to walk is often lost after neural injury, leading to multiple secondary complications that reduce quality of life and increase healthcare costs. The current rehabilitation interventions primarily focus on restoring leg movements through intensive training on a treadmill or using robotic devices, but ignore engaging the arms. Several groups have recently shown that simultaneous arm and leg (A&L) cycling improves walking function and interlimb connectivity. These findings highlight the importance of neuronal pathways between the arm (cervical) and leg (lumbar) control regions in the spinal cord during locomotion, and emphasize the need for activating these pathways to improve walking after neural injury or disease. While the findings to date provide important evidence about actively including the arms in walking rehabilitation, these strategies have yet to be optimized. Moreover, improvements beyond A&L cycling alone may be possible with conjunctive targeted strategies to enhance spinal interlimb connectivity. The aim of this review is to highlight the current evidence for improvements in walking function and neural interlimb connectivity after neural injury or disease with cycling-based rehabilitation paradigms. Furthermore, strategies to enhance the outcomes of A&L cycling as a rehabilitation strategy are explored. These include the use of functional electrical stimulation-assisted cycling in acute care settings, utilizing non-invasive transcutaneous spinal cord stimulation to activate previously inaccessible circuitry in the spinal cord, and the use of paired arm and leg rehabilitation robotics. This review aims to consolidate the effects of exercise interventions that incorporate the arms on improved outcomes for walking, functional mobility, and neurological integrity, underscoring the importance of integrating the arms into the rehabilitation of walking after neurological conditions affecting sensorimotor function. Full article

Background/Objectives: Nerve transfer surgery is a state-of-the-art surgical approach to restore hand and arm function in individuals living with tetraplegia, significantly impacting daily life. While nearly a third of all individuals with chronic spinal cord injury may benefit from this intervention, variability in outcomes can limit the functional impact. A bedside to bench approach was taken to address the variable response of tetraplegic individuals to nerve transfer surgery. Methods: We used a hierarchical multiple factor analysis to evaluate the effects of conditioning electrical stimulation (CES) on outcomes in a mouse model of nerve transfer to treat chronic cervical spinal cord injury. Results: We found that CES of donor nerves one week prior to nerve transfer surgery enhanced anatomical and functional measures of innervation of targeted muscles. Furthermore, CES increased the rate of recovery of naturalistic behavior. Conclusions: While the model has some limitations due to the small size of the rodent, our results support the use of CES as an effective approach to improve outcomes in clinical nerve repair settings. Full article

Background/Objectives: Preliminary observations support the view that spinal cord epidural stimulation (scES) combined with trunk-specific training can improve trunk stability during functional activities in individuals with thoracic spinal cord injury (SCI). We studied the acute effects of trunk-specific stimulation on sitting postural control. Methods: Twenty-three individuals with severe cervical SCI were implanted with an epidural stimulator. Postural control was assessed before any activity-based training, without and with trunk-specific scES. In particular, participants performed sitting with upright posture, forward/back lean, and lateral lean activities while sitting on a standard therapy mat. Full-body kinematics and trunk electromyography (EMG) were acquired. Anterior-posterior and lateral trunk displacement along with trunk velocity in all four directions were obtained and used to classify postural control responses. Results: Compared to no stimulation, application of trunk-specific scES led to trunk anterior–posterior displacement increases during forward/back lean (2.79 ± 0.97 cm; p-value = 0.01), and trunk lateral displacement increases during lateral lean (2.19 ± 0.79 cm; p-value = 0.01). After digital filtering of stimulation artifacts, EMG root mean square amplitudes for bilateral external oblique, rectus abdominus, and erector spinae muscles were higher with stimulation for all activities (all p-values < 0.03). Conclusions: The results indicate improvements in trunk lean distances and muscle activation when leaning activities are performed with trunk-specific epidural stimulation. Full article

Background/Objectives: To determine whether epidural electrical stimulation (EES) improves sensory recovery and walking function in patients with chronic spinal cord injury (SCI) with a grade on the American Spinal Cord Injury Association impairment scale (AIS) of C or D at the cervical level. Methods: Three individuals with cervical-level chronic AIS D SCI were enrolled in the study. The mean injury duration and age were 4.8 ± 4.5 (range: 1.5–10) and 56.7 ± 9 years, respectively. The participants received personalized electrical stimulation for 36 weeks and were evaluated for their SCI characteristics, the result of an AIS assessment according to the lower extremity sensorimotor scale, their muscle activity, and preoperative walking ability parameters, initially as well as at weeks 8 and 36 of the EES intervention. Results: Participants receiving EES significantly increased the muscle activity in most lower limb muscles. Regarding the AIS assessment of the lower extremities, one participant fully regained a light touch sensation, while two fully recovered their pinprick sensation (AIS sensory scores increased from 14 to 28). One participant achieved a full motor score, whereas the others’ scores increased by 19 and 7 points. Compared with preoperative gait parameters, two participants showed improvements in their walking speed and cadence. Walking symmetry, an important parameter for assessing walking function, improved by 68.7%, 88%, and 77% in the three participants, significantly improving the symmetry index (p = 0.003). Conclusions: Thus, EES may be an effective strategy for sensory impairment recovery, as well as muscular activity and strength improvement. These findings may facilitate stable walking in subjects with chronic incomplete SCI, but larger clinical trials are warranted. Clinical trial: NCT05433064. Full article

(1) Background: Respiratory dysfunction is a debilitating consequence of cervical and thoracic spinal cord injury (SCI), resulting from the loss of cortico-spinal drive to respiratory motor networks. This impairment affects both central and peripheral nervous systems, disrupting motor control and muscle innervation, which is essential for effective breathing. These deficits significantly impact the health and quality of life of individuals with SCI. Noninvasive stimulation techniques targeting these networks have emerged as a promising strategy to restore respiratory function. This study systematically reviewed the evidence on noninvasive electrical stimulation modalities targeting respiratory motor networks, complemented by previously unpublished data from our research. (2) Methods: A systematic search of five databases (PubMed, Ovid, Embase, Science Direct, and Web of Science) identified studies published through 31 August 2024. A total of 19 studies involving 194 participants with SCI were included. Unpublished data from our research were also analyzed to provide supplementary insights. (3) Results: Among the stimulation modalities reviewed, spinal cord transcutaneous stimulation (scTS) emerged as a particularly promising therapeutic approach for respiratory rehabilitation in individuals with SCI. An exploratory clinical trial conducted by the authors confirmed the effectiveness of scTS in enhancing respiratory motor performance using a bipolar, 5 kHz-modulated, and 1 ms pulse width modality. However, the heterogeneity in SCI populations and stimulation protocols across studies underscores the need for further standardization and individualized optimization to enhance clinical outcomes. (4) Conclusions: Developing standardized and individualized neuromodulatory protocols, addressing both central and peripheral nervous system impairments, is critical to optimizing respiratory recovery and advancing clinical implementation. Full article

Introduction: Painful legs and moving toes (PLMT) syndrome is a rare movement disorder characterized by defuse lower limb neuropathic pain and spontaneous abnormal, involuntary toe movements. Objective: The objective was to present a rare case of PLMT syndrome with a triggering area in an adult patient due to multilevel discogenic pathology, to make a thorough review of this disorder and to provide a practical approach to its management. Case presentation: A 59-years-old male was admitted to the neurology ward with symptoms of defuse pain in the lower-back and the right leg accompanied by involuntary movements for the right toes intensified by tactile stimulation in the right upper thigh. Magnetic resonance imaging (MRI) revealed a multilevel discogenic pathology of the lumbar and cervical spine, with myelopathy at C5-C7 level. A medication with Pregabalin 300 mg/daily significantly improved both the abnormal toe movements and the leg pain. The clinical effect was constant during the 90-day follow-up without any adverse effects. Conclusion: Painful legs and moving toes (PLMT) is a condition that greatly affects the quality of life of patients, but which still remains less known by clinicians. Spontaneous resolution is rare, and oral medications are the first-line treatment. Pregabalin is a safe and effective treatment option for PLMT that should be considered early for the management of this condition. Other medication interventions, such as botulinum toxin injections, spinal blockade, or non-pharmacological treatment options like spinal cord stimulation, and surgical decompressions, are also recommended when the conservative treatment is ineffective in well-selected patients. Full article

Transcutaneous spinal cord stimulation (tSCS) is a promising noninvasive alternative to epidural stimulation. However, further studies are needed to clarify how tSCS affects postural control. The aim of this study was to investigate the effect of transcutaneous cervical spinal cord stimulation on postural stability in healthy participants via computerized stabilization. The center of pressure and the frequency spectrum of the statokinesiogram were assessed in 14 healthy volunteers under tSCS conditions with frequencies of 5 Hz or 30 Hz, subthreshold or suprathreshold stimulus strength, open or closed eyes, and hard or soft surfaces in various combinations. The results revealed that not all the changes in the center of the pressure oscillations reached statistical significance when the tSCS was used. However, tSCS at a frequency of 30 Hz with a suprathreshold stimulus strength improved postural stability. The use of subthreshold or suprathreshold tSCS at 5 Hz led to a shift of 60% of the signal power to the low-frequency range, indicating activation of the vestibular system. With tSCS at 30 Hz, the vestibular component remained dominant, but a decrease in the proportion of high-frequency oscillations was observed, which is associated with muscle proprioception. Thus, transcutaneous electrical stimulation of the cervical spinal cord may be an effective method for activating spinal cord neural networks capable of modulating postural control. Full article

(1) Background. High-level spinal cord injury (SCI) disrupts trunk control, leading to an impaired performance of upright postural tasks in sitting and standing. We previously showed that a novel robotic postural stand training with spinal cord epidural stimulation targeted at facilitating standing (Stand-scES) largely improved standing trunk control in individuals with high-level motor complete SCI. Here, we aimed at assessing the effects of robotic postural stand training with Stand-scES on sitting postural control in the same population. (2) Methods. Individuals with cervical (n = 5) or high-thoracic (n = 1) motor complete SCI underwent approximately 80 sessions (1 h/day; 5 days/week) of robotic postural stand training with Stand-scES, which was performed with free hands (i.e., without using handlebars) and included periods of standing with steady trunk control, self-initiated trunk and arm movements, and trunk perturbations. Sitting postural control was assessed on a standard therapy mat, with and without scES targeted at facilitating sitting (Sit-scES), before and after robotic postural stand training. Independent sit time and trunk center of mass (CM) displacement were assessed during a 5 min time window to evaluate steady sitting control. Self-initiated antero-posterior and medial-lateral trunk movements were also attempted from a sitting position, with the goal of covering the largest distance in the respective cardinal directions. Finally, the four Neuromuscular Recovery Scale items focused on sitting trunk control (Sit, Sit-up, Trunk extension in sitting, Reverse sit-up) were assessed. (3) Results. In summary, neither statistically significant differences nor large Effect Size were promoted by robotic postural stand training for the sitting outcomes considered for analysis. (4) Conclusions. The findings of the present study, together with previous observations, may suggest that robotic postural stand training with Stand-scES promoted trunk motor learning that was posture- and/or task-specific and, by itself, was not sufficient to significantly impact sitting postural control. Full article

Lower motor neuron (LMN) damage results in denervation of the associated muscle targets and is a significant yet under-appreciated component of spinal cord injury (SCI). Denervated muscle undergoes a progressive degeneration and fibro-fatty infiltration that eventually renders the muscle non-viable unless reinnervated within a limited time window. The distal nerve deprived of axons also undergoes degeneration and fibrosis making it less receptive to axons. In this review, we describe the LMN injury associated with SCI and its clinical consequences. The process of degeneration of the muscle and nerve is broken down into the primary components of the neuromuscular circuit and reviewed, including the nerve and Schwann cells, the neuromuscular junction, and the muscle. Finally, we discuss three promising strategies to reverse denervation atrophy. These include providing surrogate axons from local sources; introducing stem cell-derived spinal motor neurons into the nerve to provide the missing axons; and finally, instituting a training program of high-energy electrical stimulation to directly rehabilitate these muscles. Successful interventions for denervation atrophy would significantly expand reconstructive options for cervical SCI and could be transformative for the predominantly LMN injuries of the conus medullaris and cauda equina. Full article

(1) Background: Restoring arm and hand function is one of the priorities of people with cervical spinal cord injury (cSCI). Noninvasive electromagnetic neuromodulation is a current approach that aims to improve upper-limb function in individuals with SCI. The aim of this study is to review updated information on the different applications of noninvasive electromagnetic neuromodulation techniques that focus on restoring upper-limb functionality and motor function in people with cSCI. (2) Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to structure the search protocol. A systematic review of the literature was performed in three databases: the Cochrane Library, PubMed, and Physiotherapy Evidence Database (PEDro). (3) Results: Twenty-five studies were included: four were on transcranial magnetic stimulation (TMS), four on transcranial direct current stimulation (tDCS), two on transcutaneous spinal cord stimulation (tSCS), ten on functional electrical stimulation (FES), four on transcutaneous electrical nerve stimulation (TENS), and one on neuromuscular stimulation (NMS). The meta-analysis could not be completed due to a lack of common motor or functional evaluations. Finally, we realized a narrative review of the results, which reported that noninvasive electromagnetic neuromodulation combined with rehabilitation at the cerebral or spinal cord level significantly improved upper-limb functionality and motor function in cSCI subjects. Results were significant compared with the control group when tSCS, FES, TENS, and NMS was applied. (4) Conclusions: To perform a meta-analysis and contribute to more evidence, randomized controlled trials with standardized outcome measures for the upper extremities in cSCI are needed, even though significant improvement was reported in each non-invasive electromagnetic neuromodulation study. Full article