Effects of Long-Term Paired Associative Stimulation on Strength of Leg Muscles and Walking in Chronic Tetraplegia: A Proof-of-Concept Pilot Study

Andrei Rodionov, Sarianna Savolainen, Erika Kirveskari, Jyrki P Mäkelä, Anastasia Shulga, Andrei Rodionov, Sarianna Savolainen, Erika Kirveskari, Jyrki P Mäkelä, Anastasia Shulga

Abstract

Recovery of lower-limb function after spinal cord injury (SCI) is dependent on the extent of remaining neural transmission in the corticospinal pathway. The aim of this proof-of-concept pilot study was to explore the effects of long-term paired associative stimulation (PAS) on leg muscle strength and walking in people with SCI. Five individuals with traumatic incomplete chronic tetraplegia (>34 months post-injury, motor incomplete, 3 females, mean age 60 years) with no contraindications to transcranial magnetic stimulation (TMS) received PAS to one or both legs for 2 months (28 sessions in total, 5 times a week for the first 2 weeks and 3 times a week thereafter). The participants were evaluated with the Manual Muscle Test (MMT), AIS motor and sensory examination, Modified Asworth Scale (MAS), and the Spinal Cord Independence Measure (SCIM) prior to the intervention, after 1 and 2 months of PAS, and after a 1-month follow-up. The study was registered at clinicaltrials.gov (NCT03459885). During the intervention, MMT scores and AIS motor scores increased significantly (p = 0.014 and p = 0.033, respectively). Improvements were stable in follow-up. AIS sensory scores, MAS, and SCIM were not modified significantly. MMT score prior to intervention was a good predictor of changes in walking speed ( R adj 2 = 0.962). The results of this proof-of-concept pilot study justify a larger trial on the effect of long-term PAS on leg muscle strength and walking in people with chronic incomplete SCI.

Keywords: TMS; neuroplasticity; paired associative stimulation; spinal cord injury; walking.

Copyright © 2020 Rodionov, Savolainen, Kirveskari, Mäkelä and Shulga.

Figures

Figure 1
Figure 1
Time course of intervention.
Figure 2
Figure 2
Medians of MMT scores (left) and AIS motor scores (right) before the intervention (Pre-PAS), after 1 month (Mid-PAS), and after 2 months (Post-PAS) of stimulations and in the 1-month follow-up. Asterisks show significant differences (n = 5, p < 0.05).
Figure 3
Figure 3
Relationship between the sum of the MMT scores collected in stimulated lower limbs prior the intervention (Pre-PAS) from the key muscles (left) and remaining muscles (right) and changes in walking speed obtained during follow-up. Linear regression—solid and dashed lines. R—only right leg was stimulated, L—only left leg was stimulated, B—both legs were stimulated.

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