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

Stephen Estes, Anastasia Zarkou, Jasmine M Hope, Cazmon Suri, Edelle C Field-Fote, Stephen Estes, Anastasia Zarkou, Jasmine M Hope, Cazmon Suri, Edelle C Field-Fote

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 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.

Keywords: activity-based therapy; gait; locomotion; neuromodulation; paraplegia; task-specific training; tetraplegia; use-dependent plasticity.

Conflict of interest statement

The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in the decision to publish the results.

Figures

Figure 1
Figure 1
Study design.
Figure 2
Figure 2
Flow diagram.
Figure 3
Figure 3
Walking speed. The mean walking speed (bold black line) increased in both the LT + TSSsham (left) and LT + TSS (center) groups over time. Note that the colored lines represent the mean walking speeds of individual participants. The change in mean walking speed, calculated from the start and end of each 2-week LT phase (T1 to T2, T3 to T4; right) showed improvements in both groups; however, only the LT + TSS group showed continued significant improvements during the 2-week TSS intervention phase. W: Wash-in; I: Intervention. Error bars represent standard errors; * p < 0.05.
Figure 4
Figure 4
Walking distance. The average walking distance (bold black line) increased in both the LT + TSSsham (left) and LT + TSS (center) groups over time. Note that the colored lines represent the average walking distance of individual participants. The change in mean walking distance calculated from the start and end of each 2-week LT bout (T1 to T2, T3 to T4; right) showed significant improvements in the LT + TSSsham group during the wash-in phase; whereas the LT + TSS group showed significant improvements during the intervention phase. W: Wash-in; I: Intervention. Error bars represent standard errors; * p < 0.05.
Figure 5
Figure 5
Step length asymmetry. Mean step length asymmetry (bold black line) remained the same in both the LT + TSSsham (left) and LT + TSS (center) groups over time. Colored lines represent the mean step length asymmetry of individual participants. Change in mean step length asymmetry calculated from the start and end of each 2-week LT bout (T1 to T2, T3 to T4; right) showed only a small improvement in the LT + TSSsham group. W: Wash-in; I: Intervention. Error bars represent standard errors.
Figure 6
Figure 6
Pendulum test outcomes. No significant change in mean first swing excursion (FSE) was observed in participants in the LT + TSSsham group in either the more impaired (upper left) or less impaired (lower left) limb. Likewise, no significant change in mean first swing excursion (FSE) was observed in participants in the LT + TSS group in either the more impaired (upper right) or less impaired (lower right) limb.
Figure 7
Figure 7
Drop test outcomes. No significant change in mean number of oscillations was observed in participants in the LT + TSSsham group in either the more impaired (upper left) or less impaired (lower left) limb. Likewise, no significant change in mean number of oscillations was observed in participants in the LT + TSS group in either the more impaired (upper right) or less impaired (lower right) limb.

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