Neuromodulation of lower limb motor control in restorative neurology

Karen Minassian, Ursula Hofstoetter, Keith Tansey, Winfried Mayr, Karen Minassian, Ursula Hofstoetter, Keith Tansey, Winfried Mayr

Abstract

One consequence of central nervous system injury or disease is the impairment of neural control of movement, resulting in spasticity and paralysis. To enhance recovery, restorative neurology procedures modify altered, yet preserved nervous system function. This review focuses on functional electrical stimulation (FES) and spinal cord stimulation (SCS) that utilize remaining capabilities of the distal apparatus of spinal cord, peripheral nerves and muscles in upper motor neuron dysfunctions. FES for the immediate generation of lower limb movement along with current rehabilitative techniques is reviewed. The potential of SCS for controlling spinal spasticity and enhancing lower limb function in multiple sclerosis and spinal cord injury is discussed. The necessity for precise electrode placement and appropriate stimulation parameter settings to achieve therapeutic specificity is elaborated. This will lead to our human work of epidural and transcutaneous stimulation targeting the lumbar spinal cord for enhancing motor functions in spinal cord injured people, supplemented by pertinent human research of other investigators. We conclude that the concept of restorative neurology recently received new appreciation by accumulated evidence for locomotor circuits residing in the human spinal cord. Technological and clinical advancements need to follow for a major impact on the functional recovery in individuals with severe damage to their motor system.

Copyright © 2012 Elsevier B.V. All rights reserved.

Figures

Fig. 1
Fig. 1
Lower limb motor activity generated by epidural lumbar SCS. (A) Drawing of a cylindrical epidural lead with four contacts (black rectangles) placed over the posterior aspect of the lumbar spinal cord. (B) Locomotor-like EMG activities of paralyzed lower limb muscles elicited by sustained epidural lumbar SCS at 25 Hz and 10 V in a supine position. Q: quadriceps, Ham: hamstrings, TA: tibialis anterior, TS: triceps surae. Induced relative knee movements (Knee mov.) are documented by a position sensor trace; deflection up indicates knee flexion. Data derived from a subject with chronic, motor-complete (AIS B), mid-thoracic (motor level: T8) traumatic SCI . (C) Extension movement and associated EMG activity induced by epidural lumbar SCS at 10 Hz and 10 V. The subject's lower limb had been placed in a flexed position prior to the onset of stimulation (see vertical arrow along the time-axis). The goniometer trace (Knee angle) illustrates the generated extension movement. Data derived from a subject with chronic, motor-complete (AIS A), mid-thoracic (motor level: T6) traumatic SCI in supine position . (D) Lower limb EMG activity induced by manually assisted, body-weight supported treadmill walking without (left side) and with additional epidural lumbar SCS. The treadmill belt speed was 0.36 m/s. The subject wore a parachute harness connected to counterweights which supported him vertically over the treadmill and provided 50% body weight support. Two physiotherapists manually imposed the stepping motions on the moving treadmill belt. No independent functional movements were produced. Black horizontal bars indicate stance phases. Subject with chronic, motor-complete (AIS A), low-cervical (motor level: C6) traumatic SCI .
Fig. 2
Fig. 2
Lower limb motor activity generated by transcutaneous lumbar SCS. (A) Stimulation method of transcutaneous SCS. Drawings of the stimulating paravertebral and abdominal reference electrodes with respect to the spine and spinal cord. (B) EMG activities generated in paralyzed lower limb muscles by partial (50%) body-weight supported and manually assisted treadmill stepping without (left) and with sub-motor transcutaneous SCS. EMG recordings were derived from the right quadriceps (Q), hamstrings (Ham), tibialis anterior (TA), and triceps surae (TS) along with goniometric data from the knee (Knee angle). Black bars mark stance phases; treadmill speed was 0.33 m/s. Continuous transcutaneous SCS at 30 Hz and 25 V produced rhythmic gait-synchronized EMG activities. Lower limb motor threshold was 28 V in a supported standing position. Subject with chronic, motor-complete (AIS A), mid-thoracic (motor level: T6) traumatic SCI. (C) EMG activities generated in paralyzed lower limbs by partial (50%) body-weight supported and manually assisted treadmill stepping without (left) and with above-motor threshold transcutaneous SCS; treadmill belt speed was 0.39 m/s. Transcutaneous SCS at 30 Hz and 35 V produced burst-like activities in all right lower limb muscles, with in-phase oscillation that were not synchronized to the manually controlled step-cycle. Lower limb motor threshold was 25 V in a passive supported standing position. Subject with chronic, motor-complete (AIS B), low-cervical (motor level: C6) traumatic SCI.

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