Spinal Cord Epidural Stimulation for Lower Limb Motor Function Recovery in Individuals with Motor Complete Spinal Cord Injury

https://doi.org/10.1016/j.pmr.2018.12.009Get rights and content

Section snippets

Key points

  • Spinal cord epidural stimulation can neuromodulate the human spinal circuitry controlling posture and locomotion, which remains most often intact below the level of injury, by primarily recruiting dorsal root fibers carrying somatosensory information.

  • Spinal cord epidural stimulation, sensory feedback, and clinically undetected, residual volitional descending input can synergistically contribute to motor function recovery after chronic, motor complete spinal cord injury.

  • The selection of spinal

Spinal cord characteristics underlying spinal stimulation- and training-induced motor recovery after spinal cord injury

Spinal cord stimulation and activity-based training aim at capitalizing on the human spinal cord sensory-motor potential that still persists after chronic, clinically complete SCI. In particular, (i) automaticity, (ii) residual supraspinal connections to the spinal circuitry, and (iii) plasticity are briefly discussed in this section.

Spinal cord epidural stimulation, sensory feedback, and residual volitional descending input: synergic contribution for motor function recovery after spinal cord injury

Decades of work on animal models with complete SCI initially suggested to apply scES with the goal of modulating the excitability of spinal circuitry, mimicking the tonic supraspinal drive lost after SCI, so that sensory information from lower limbs could serve as a source of control for generating appropriate motor patterns during standing and stepping.9 In addition, the serendipitous findings related to the reenabling of volitional lower limb movements using scES led to further efforts aimed

Future directions

Future studies with a larger number of SCI individuals and broader range of age and time since injury, among others, are needed to better understand the mechanisms underlying motor recovery after severe SCI using scES, as well as its potential for translation to the home and community environment. Similarly, it will be important to identify neurophysiological and imaging markers that may predict which individuals are more likely to benefit from this intervention. Technological advancements are

Acknowledgments

The authors thank Dr Susan Harkema for her helpful feedback on the article. The authors are supported by The Leona M. and Harry B. Helmsley Charitable Trust, Craig H. Neilsen Foundation, and Christopher & Dana Reeve Foundation.

First page preview

First page preview
Click to open first page preview

References (97)

  • L.S. Illis et al.

    Dorsal-column stimulation in the rehabilitation of patients with multiple sclerosis

    Lancet

    (1976)
  • Y.P. Gerasimenko et al.

    Spinal cord reflexes induced by epidural spinal cord stimulation in normal awake rats

    J Neurosci Methods

    (2006)
  • P. Musienko et al.

    Multi-system neurorehabilitative strategies to restore motor functions following severe spinal cord injury

    Exp Neurol

    (2012)
  • E.M. Moraud et al.

    Mechanisms underlying the neuromodulation of spinal circuits for correcting gait and balance deficits after spinal cord injury

    Neuron

    (2016)
  • S. Arber

    Motor circuits in action: specification, connectivity, and function

    Neuron

    (2012)
  • K. Minassian et al.

    Human lumbar cord circuitries can be activated by extrinsic tonic input to generate locomotor-like activity

    Hum Mov Sci

    (2007)
  • Y. Gerasimenko et al.

    Epidural stimulation: comparison of the spinal circuits that generate and control locomotion in rats, cats and humans

    Exp Neurol

    (2008)
  • P.J. Grahn et al.

    Enabling task-specific volitional motor functions via spinal cord neuromodulation in a human with paraplegia

    Mayo Clin Proc

    (2017)
  • Y. Gerasimenko et al.

    Transcutaneous electrical spinal-cord stimulation in humans

    Ann Phys Rehabil Med

    (2015)
  • M. Possover

    Recovery of sensory and supraspinal control of leg movement in people with chronic paraplegia: a case series

    Arch Phys Med Rehabil

    (2014)
  • M.L. Jones et al.

    Activity-based therapy for recovery of walking in individuals with chronic spinal cord injury: results from a randomized clinical trial

    Arch Phys Med Rehabil

    (2014)
  • R.L. Waters et al.

    Recovery following complete paraplegia

    Arch Phys Med Rehabil

    (1992)
  • A. Curt et al.

    Recovery from a spinal cord injury: significance of compensation, neural plasticity, and repair

    J Neurotrauma

    (2008)
  • Y.P. Gerasimenko et al.

    Noninvasive reactivation of motor descending control after paralysis

    J Neurotrauma

    (2015)
  • Y. Gerasimenko et al.

    Novel and direct access to the human locomotor spinal circuitry

    J Neurosci

    (2010)
  • A. Toossi et al.

    Mechanically stable intraspinal microstimulation implants for human translation

    Ann Biomed Eng

    (2017)
  • V.R. Edgerton et al.

    Plasticity of the spinal neural circuitry after injury

    Annu Rev Neurosci

    (2004)
  • S. Grillner

    Neurobiological bases of rhythmic motor acts in vertebrates

    Science

    (1985)
  • M. Hubli et al.

    The physiological basis of neurorehabilitation--locomotor training after spinal cord injury

    J Neuroeng Rehabil

    (2013)
  • L.P. Hiersemenzel et al.

    From spinal shock to spasticity: neuronal adaptations to a spinal cord injury

    Neurology

    (2000)
  • J. Beauparlant et al.

    Undirected compensatory plasticity contributes to neuronal dysfunction after severe spinal cord injury

    Brain

    (2013)
  • S.J. Harkema et al.

    Human lumbosacral spinal cord interprets loading during stepping

    J Neurophysiol

    (1997)
  • M.P. Cote et al.

    Rehabilitation strategies after spinal cord injury: inquiry into the mechanisms of success and failure

    J Neurotrauma

    (2017)
  • B.A. Kakulas

    Neuropathology: the foundation for new treatments in spinal cord injury

    Spinal Cord

    (2004)
  • W.B. McKay et al.

    Clinical neurophysiological assessment of residual motor control in post-spinal cord injury paralysis

    Neurorehabil Neural Repair

    (2004)
  • M.R. Dimitrijevic et al.

    Suprasegmentally induced motor unit activity in paralyzed muscles of patients with established spinal cord injury

    Ann Neurol

    (1984)
  • R.D. De Leon et al.

    Full weight-bearing hindlimb standing following stand training in the adult spinal cat

    J Neurophysiol

    (1998)
  • R.D. de Leon et al.

    Locomotor capacity attributable to step training versus spontaneous recovery after spinalization in adult cats

    J Neurophysiol

    (1998)
  • V.R. Edgerton et al.

    Activity-dependent plasticity of spinal locomotion: implications for sensory processing

    Exerc Sport Sci Rev

    (2009)
  • G. Courtine et al.

    Transformation of nonfunctional spinal circuits into functional states after the loss of brain input

    Nat Neurosci

    (2009)
  • J.C. Petruska et al.

    Changes in motoneuron properties and synaptic inputs related to step training after spinal cord transection in rats

    J Neurosci

    (2007)
  • J. Cha et al.

    Locomotor ability in spinal rats is dependent on the amount of activity imposed on the hindlimbs during treadmill training

    J Neurotrauma

    (2007)
  • J.A. Hodgson et al.

    Can the mammalian lumbar spinal cord learn a motor task?

    Med Sci Sports Exerc

    (1994)
  • P.K. Shah et al.

    Variability in step training enhances locomotor recovery after a spinal cord injury

    Eur J Neurosci

    (2012)
  • L.L. Cai et al.

    Implications of assist-as-needed robotic step training after a complete spinal cord injury on intrinsic strategies of motor learning

    J Neurosci

    (2006)
  • M. Knikou

    Plasticity of corticospinal neural control after locomotor training in human spinal cord injury

    Neural Plast

    (2012)
  • W.H. Sweet et al.

    Stimulation of the posterior columns of the spinal cord for pain control: indications, technique, and results

    Clin Neurosurg

    (1974)
  • A.W. Cook et al.

    Chronic dorsal column stimulation in multiple sclerosis. Preliminary report

    N Y State J Med

    (1973)
  • Cited by (0)

    Disclosure Statement: The authors have nothing to disclose.

    View full text