Does Neuromuscular Electrical Stimulation Therapy Increase Voluntary Muscle Strength After Spinal Cord Injury? A Systematic Review

Perspectives on Barriers to Use and Benefits of Functional Electrical Stimulation From Australians and New Zealanders With SCI and Clinicians and Researchers in the Field

Objectives

To document, through a survey, perceptions of functional electrical stimulation (FES) from people with spinal cord injury (SCI) and carers, clinicians, and researchers (CCR).

Methods

Online questionnaires were completed in Australia and New Zealand from December 1, 2021 to August 31, 2022. Subgroups included people with SCI who have used FES, people with SCI who have not used FES, CCRs who have used FES, and CCRs who have not used FES. Frequencies and percentages of subgroup data were calculated for all questions. Open-ended responses were analyzed with inductive content analysis.

Results

Ninety-nine responses (70 people with SCI, 29 CCR) were analyzed. Out of the 99 responses, 47 people with SCI and 27 CCRs had used or currently use FES. Muscle strength was the most frequently reported benefit by people with SCI and CCRs who use(d) FES. Lack of training was the most frequently reported barrier to FES by people with SCI (85% of question responders) and CCRs (94%) who had used FES. People with SCI (95%) who had not used FES reported access as a barrier. The leading priorities for future research include improved ease of use for people with SCI (60% people with SCI) and clinical guidelines (48% CCR). Qualitative findings supported the quantitative findings.

Conclusion

This survey identified access as a barrier to FES and echoed benefits (strength) and barriers (training) reported in previous research. Ameliorating the barriers and investigating the areas of future research identified in this study will ultimately improve FES uptake in SCI rehabilitation.

Non-invasive Transcutaneous Spinal Cord Stimulation Programming Recommendations for the Treatment of Upper Extremity Impairment in Tetraplegia

OBJECTIVES

This study analyzes the stimulation parameters implemented during two successful trials that used non-invasive transcutaneous spinal cord stimulation (tSCS) to effectively improve upper extremity function after chronic spinal cord injury (SCI). It proposes a framework to guide stimulation programming decisions for the successful translation of these techniques into the clinic.

MATERIALS AND METHODS

Programming data from 60 participants who completed the Up-LIFT trial and from 17 participants who subsequently completed the LIFT Home trial were analyzed. All observations of stimulation amplitudes, frequencies, waveforms, and electrode configurations were examined. The incidence of adverse events and relatedness to stimulation parameters is reported. A comparison of parameter usage across the American Spinal Injury Association Impairment Scale (AIS) subgroups was conducted to evaluate stimulation strategies across participants with varying degrees of sensorimotor preservation.

RESULTS

Active (cathodal) electrodes were typically placed between the C3/C4 and C6/C7 spinous processes. Most sessions featured return (anodal) electrodes positioned bilaterally over the anterior superior iliac spine, although clavicular placement was frequently used by 12 participants. Stimulation was delivered with a 10-kHz carrier frequency and typically a 30-Hz burst frequency. Biphasic waveforms were used in 83% of sessions. Average stimulation amplitudes were higher for biphasic waveforms. The AIS B subgroup required significantly higher amplitudes than did the AIS C and D subgroups. Device-related adverse events were infrequent, and not correlated with specific waveforms or amplitudes. Within the home setting, participants maintained their current amplitudes within 1% of the preset values. The suggested stimulation programming framework dictates the following hierarchical order of parameter adjustments: current amplitude, waveform type, active/return electrode positioning, and burst frequency, guided by clinical observations as required.

CONCLUSIONS

This analysis summarizes effective stimulation parameters from the trials and provides a decision-making framework for clinical implementation of tSCS for upper extremity functional restoration after SCI. The parameters are aligned with existing literature and proved safe and well tolerated by participants.

The Effect of Physiotherapy on Arthrogenic Muscle Inhibition After ACL Injury or Reconstruction: A Systematic Review

Arthrogenic muscle inhibition (AMI) following ACL injury or reconstruction is a common issue that affects muscle activation and functional recovery. Thus, the objective of this study was to systematize the literature on the effects of physiotherapy interventions in the rehabilitation of AMI after ACL injury or reconstruction. A systematic review was conducted following the PRISMA guidelines. The risk of bias was evaluated using the PEDro scale and the Cochrane risk of bias tool. Searches were performed in the PubMed, Google Scholar, Cochrane Library, and EMBASE databases. Randomized controlled trials involving patients with ACL injuries or ACL reconstruction were included. Twenty studies were included. Fifteen evaluated the effects of exercise, showing significant improvement. Seven studies examined electrotherapy, with neuromuscular electrical stimulation and high-frequency therapy combined with exercise showing improvements in muscle strength, pain, and joint range of motion. Nine studies explored interventions like motor imagery, cryotherapy, taping, and vibration. When performed before exercise, motor imagery and cryotherapy improved cortical activity and muscle recovery. Kinesio taping reduced edema and pain better than exercise alone. Vibration showed inconsistent results across three studies. Methodological quality varied between 5 and 8 on the PEDro scale, with moderate-to-low risk of bias. Structured exercise should be the first-line intervention, but combining it with other therapies enhances rehabilitation. The study protocol was registered in the PROSPERO database (CRD42023425510).

Effects of Neuromuscular Electrical Stimulation for Quadriceps Muscle Thickness and Lower Extremity Motor Score in Individuals with Subacute Incomplete Cervical Spinal Cord Injury: A Randomized Controlled Trial

OBJECTIVE

In this study, we aimed to determine the effects of 2-week neuromuscular electrical stimulation (NMES) on quadriceps muscle atrophy and lower extremity motor score in individuals with subacute incomplete cervical spinal cord injury (SCI).

METHODS

This stratified randomized controlled trial, conducted in the advanced critical care center of a university hospital, comprised 49 individuals with American Spinal Injury Association (ASIA) impairment scale grade C and D incomplete cervical SCI. The participants were stratified based on the ASIA impairment scale grade and randomly assigned to the control (n = 25) or NMES (n = 24) group. The control group participants received only conventional rehabilitation; the NMES group participants received conventional rehabilitation plus NMES in the quadriceps muscles of both lower limbs. The primary endpoints were quadriceps muscle thickness and L3 ASIA lower extremity motor score (L3 motor score), measured at the study's initiation and after 2 weeks.

RESULTS

The quadriceps muscle thickness changes on the stronger and weaker sides were -14.2% ± 11.3% and -15.1% ± 13.8%, respectively, in the NMES group and -25.7% ± 16.8% and -26.0% ± 13.3%, respectively, in the control group, indicating significantly lesser reduction on both sides in the NMES group (p <0.05). The L3 motor scores on the stronger and weaker sides were 0.8 ± 1.2 and 1.3 ± 1.4 (NMES group) and 0.4 ± 0.8 and 0.4 ± 0.8 (control group), respectively, indicating significant improvement only on the weaker side (p <0.05).

CONCLUSIONS

For subacute incomplete cervical SCI, 2 weeks of NMES reduces quadriceps muscle atrophy and improves the L3 motor score values on the weaker side compared with standard treatment.

Electrical Stimulation Prevents Muscular Atrophy and the Decrease of Interleukin-6 in Paralyzed Muscles after Spinal Cord Injury in Rats

Objective  To analyze the muscle trophism and expression of interleukin-6 in the biceps brachii muscle of rats with incomplete cervical spinal cord injury treated with neuromuscular electrical stimulation (NMES). Methods  Adult rats underwent C5-C7 spinal cord hemisection and a 5-week NMES protocol. Trophism of the biceps brachii was assessed using muscle weight/body weight ratio and histological analysis. Interleukin-6 expression from biceps brachii was measured using the enzyme-linked immunosorbent assay technique. Results  Preservation of the biceps brachii muscle trophism was found in the NMES treated group, along with prevention of the reduction of interleukin-6 levels. Conclusion  Spinal cord injury causes muscle atrophy and decreases interleukin-6 levels. These alterations are partially prevented by NMES. The results suggest a possible NMES action mechanism and underscore the clinical use of this therapeutic tool.

Rehabilitation report of 2 cases of spinal cord ischemic injury after intra-aortic repair

RATIONALE

Spinal cord ischemia injury is a serious complication after intra-aortic surgery, with a low incidence but high disability rate. However, patients often do not receive comprehensive treatment in the early stages of the disease. Therefore, active neurological intervention is needed to protect and prevent spinal cord ischemia during and after surgery. In this paper, rehabilitation program and imaging data of 2 cases with spinal cord ischemic injury are presented and discussed regarding causes, prevention and acute treatment with this disease, which could be referred by clinicians.

PATIENT CONCERNS

Case report 1: A 69-year-old male patient underwent aortic arch aneurysm and thoracic endovascular aortic repair (coated stent) was performed under general anesthesia. Complete paralysis of both lower limbs, constipation, and urinary retention occurred after surgery and was subsequently referred to our rehabilitation department. Case report 2: A man aged 41 years experienced sudden chest pain with no dizziness or headache. Weakness of both lower limbs gradually appeared over 30 minutes with subsequent loss of consciousness. He was diagnosed with aortic dissection and underwent aortic stent implantation. Inpatient rehabilitation began systematically 3 months after discharge.

DIAGNOSES

The 2 patients were diagnosed with paraplegia and spinal cord ischemic injury.

INTERVENTIONS

The patients received strength and transfer training, sensory input, health mission, and activities of daily living.

OUTCOMES

Patient 1 returned home without assistive devices and patient 2 returned home with wheelchair.

LESSONS

Perioperative spinal cord protection is directly related to postoperative quality of life. Once the symptoms of spinal cord ischemic injury occur, cerebrospinal fluid drainage should be performed as soon as possible to increase mean arterial pressure. At the same time, methylprednisolone, ganglioside, anticoagulation, vasodilator drugs, and symptomatic supportive treatments are required. Intercostal artery and subclavian artery are reconstructed if necessary. Symptom stability flags referral to commence rehabilitation. Repetitive functional training is necessary to help patients return to the family and society as soon as possible.

The Clinical Management of Electrical Stimulation Therapies in the Rehabilitation of Individuals with Spinal Cord Injuries

Background: People with spinal cord injuries (SCIs) often have trouble remaining active because of paralysis. In the past, exercise recommendations focused on the non-paralyzed muscles in the arms, which provides limited benefits. However, recent studies show that electrical stimulation can help engage the paralyzed extremities, expanding the available muscle mass for exercise. Methods: The authors provide an evidence-based approach using expertise from diverse fields, supplemented by evidence from key studies toward the management of electrical stimulation therapies in individuals with SCIs. Literature searches were performed separately using the PubMed, Medline, and Google Scholar search engines. The keywords used for the searches included functional electrical stimulation cycling, hybrid cycling, neuromuscular electrical stimulation exercise, spinal cord injury, cardiovascular health, metabolic health, muscle strength, muscle mass, bone mass, upper limb treatment, diagnostic and prognostic use of functional electrical stimulation, tetraplegic hands, and hand deformities after SCI. The authors recently presented this information in a workshop at a major rehabilitation conference. Additional information beyond what was presented at the workshop was added for the writing of this paper. Results: Functional electrical stimulation (FES) cycling can improve aerobic fitness and reduce the risk of cardiovascular and metabolic diseases. The evidence indicates that while both FES leg cycling and neuromuscular electrical stimulation (NMES) resistance training can increase muscle strength and mass, NMES resistance training has been shown to be more effective for producing muscle hypertrophy in individual muscle groups. The response to the electrical stimulation of muscles can also help in the diagnosis and prognosis of hand dysfunction after tetraplegia. Conclusions: Electrical stimulation activities are safe and effective methods for exercise and testing for motor neuron lesions in individuals with SCIs and other paralytic or paretic conditions. They should be considered part of a comprehensive rehabilitation program in diagnosing, prognosing, and treating individuals with SCIs to improve function, physical activity, and overall health.

Is functional electrical stimulation effective in improving walking in adults with lower limb impairment due to an upper motor neuron lesion? An umbrella review

PURPOSE

To conduct an umbrella review of systematic reviews on functional electrical stimulation (FES) to improve walking in adults with an upper motor neuron lesion.

METHODS

Five electronic databases were searched, focusing on the effect of FES on walking. The methodological quality of reviews was evaluated using AMSTAR2 and certainty of evidence was established through the GRADE approach.

RESULTS

The methodological quality of the 24 eligible reviews (stroke, n = 16; spinal cord injury (SCI), n = 5; multiple sclerosis (MS); n = 2; mixed population, n = 1) ranged from critically low to high. Stroke reviews concluded that FES improved walking speed through an orthotic (immediate) effect and had a therapeutic benefit (i.e., over time) compared to usual care (low certainty evidence). There was low-to-moderate certainty evidence that FES was no better or worse than an Ankle Foot Orthosis regarding walking speed post 6 months. MS reviews concluded that FES had an orthotic but no therapeutic effect on walking. SCI reviews concluded that FES with or without treadmill training improved speed but combined with an orthosis was no better than orthosis alone. FES may improve quality of life and reduce falls in MS and stroke populations.

CONCLUSION

FES has orthotic and therapeutic benefits. Certainty of evidence was low-to-moderate, mostly due to high risk of bias, low sample sizes, and wide variation in outcome measures. Future trials must be of higher quality, use agreed outcome measures, including measures other than walking speed, and examine the effects of FES for adults with cerebral palsy, traumatic and acquired brain injury, and Parkinson's disease.

Spatial characteristics of reactive stepping among people living with chronic incomplete spinal cord injury

Objective: Compare the spatial characteristics of reactive stepping between individuals with chronic motor incomplete spinal cord injuries (iSCI) and able-bodied (AB) individuals.Design: Cross sectional.Setting: Lyndhurst Centre.Participants: Twelve individuals with iSCI (3 males, 53.6 ± 15.2 years old) and 11 age- and sex-matched AB individuals (3 males, 54.8 ± 14.0 years old).Interventions: The Lean-and-Release test was used to elicit reactive stepping. A horizontal cable, attached at waist height, was released when 8-12% body weight was supported in a forward lean position. Participants underwent up to 10 Lean-and-Release trials in a session. Kinematic and kinetic data were recorded.Outcome measures: The length, width and height of the first reactive step of each trial were calculated. Standard deviation between trials was calculated to represent the variability in step length, width and height within a participant. Among participants with iSCI, correlation coefficients were used to explore the relationship between step length and width variability and (1) Lean-and-Release test behavioral responses, (2) 3-month fall history, and (3) lower extremity strength.Results: Step length (P = 0.94), width (P = 0.52) and height (P = 0.97), normalized for participant height, did not differ between groups. Participants with iSCI showed greater variability in step length (P = 0.02) and width (P = 0.01), but not height (P = 0.32). No correlation was found between step length or width variability and behavioral responses, 3-month fall history, or lower extremity strength.Conclusions: Individuals with iSCI showed increased variability in length and width of reactive stepping compared to AB individuals, which may contribute to their impaired ability to execute single-step reactive responses.Trial registration: ClinicalTrials.gov identifier: NCT02960178.

Neuromuscular disorders in women and men with spinal cord injury are associated with changes in muscle and tendon architecture

OBJECTIVE

The present study aimed to determine the association between neuromuscular function, motor function impairment, and muscle and tendon structures in individuals with spinal cord injury (SCI) compared to a control (non-disabled) population.

DESIGN

A cross-sectional study with a control group.

SETTING

Center of Adapted Sports Training and Special Physical Education.

PARTICIPANTS

Fifteen individuals with SCI and motor function impairments participated in the study. A paired non-disabled group was recruited for comparison.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Muscle (biceps brachii, rectus femoris, vastus lateralis, vastus medialis, and tibialis anterior) and tendon (quadriceps and patellar tendons) structures were assessed by ultrasound imaging (thickness, pennation angle, fascicle length, and echogenicity). Neuromuscular electrophysiological disorders were also assessed using electrodiagnosis techniques (stimulus non-responsivity and chronaxie) in the same muscles.

RESULTS

Except for the biceps brachii muscle, muscle thickness, pennation angle, and fascicle length were lower (p < 0.01) while echogenicity and chronaxie were greater (p < 0.01) in SCI participants. The SCI participants had a higher prevalence of neuromuscular electrophysiological disorders for all muscles, except the biceps brachii.

CONCLUSION

Neuromuscular disorders occur in association with muscle and tendon maladaptation in individuals with chronic SCI. A higher prevalence of electrophysiological disorders suggests an acquired polyneuromyopathy for muscles with motor function impairment even though the muscle was innerved, in addition to widespread muscle atrophy.

Effects of exercise training on neurological recovery, TGF-β1, HIF-1α, and Nogo-NgR signaling pathways after spinal cord injury in rats

OBJECTIVE

To evaluate the effects of exercise training on neurological recovery, Growth Transforming Factor-β1 (TGF-β1), Hypoxia Inducible Factor-1α (HIF-1α), and Nogo-NgR signaling pathways after spinal cord injury in rats.

METHODS

Forty-eight male Sprague-Dawley rats were randomly divided into four groups: normal group, sham-operated group, model group, and training group. The rat spinal cord injury model was established using Allen's method, and the training group received exercise training on the 8th day postoperatively. The Basso, Beattie and Bresnahan (BBB) score, modified Tarlow score, and inclined plane test scores were compared in each group before injury and 1, 7, 14, 21 and 28 days after injury.

RESULTS

The BBB score and modified Tarlow score of the model group and the training group were 0 at the first day after the injury, and gradually increased on the seventh day onwards (p < 0.05). The BBB score and modified Tarlow score of the training group were higher than those of the model group at the 14th, 21st and 28th day (p < 0.05). The angles of the inclined plate at multiple time points after injury were lower in the model group and the training group than in the normal group and the sham-operated group (p < 0.05); The angles of the inclined plate at the 14th, 21st and 28th day after injury were higher in the training group than in the model group (p < 0.05).

CONCLUSION

The mechanism of exercise training may be connected to the inhibition of the Nogo-NgR signaling pathway to promote neuronal growth.

Beneficial impacts of neuromuscular electrical stimulation on muscle structure and function in the zebrafish model of Duchenne muscular dystrophy

Neuromuscular electrical stimulation (NMES) allows activation of muscle fibers in the absence of voluntary force generation. NMES could have the potential to promote muscle homeostasis in the context of muscle disease, but the impacts of NMES on diseased muscle are not well understood. We used the zebrafish Duchenne muscular dystrophy (dmd) mutant and a longitudinal design to elucidate the consequences of NMES on muscle health. We designed four neuromuscular stimulation paradigms loosely based on weightlifting regimens. Each paradigm differentially affected neuromuscular structure, function, and survival. Only endurance neuromuscular stimulation (eNMES) improved all outcome measures. We found that eNMES improves muscle and neuromuscular junction morphology, swimming, and survival. Heme oxygenase and integrin alpha7 are required for eNMES-mediated improvement. Our data indicate that neuromuscular stimulation can be beneficial, suggesting that the right type of activity may benefit patients with muscle disease.

Electrical stimulation and virtual reality-guided balance training for managing paraplegia and trunk dysfunction due to spinal cord infarction

A 41-year-old woman presented with spinal cord infarction and paraplegia after acute thoracoabdominal aortic dissection. Clinical evaluation revealed the American Spinal Injury Association (ASIA) lower limb exercise score of 0 points and the Functional Assessment for Control of Trunk (FACT) score of 0 points. Conventional physical therapy for 60 days did not significantly improve the paraplegia or FACT score; therefore, belt electrode skeletal muscle electrical stimulation (B-SES) and virtual reality (VR)-guided sitting balance training were introduced for 30 days. She developed independence for all basic movements and her gait was restored using short leg braces and Lofstrand crutches. At discharge, her ASIA lower limb exercise score was 24 and FACT score was 7, with a functional impedance measure motor item of 57, and she could continuously walk for a distance of 150 m. The combination of B-SES and VR-guided balance training may be a feasible therapeutic option after spinal cord infarction.

Effect of neuromuscular electrical stimulation combined with swallowing rehabilitation training on the treatment efficacy and life quality of stroke patients with dysphagia

PURPOSE

To explore the therapeutic efficacy of neuromuscular electrical stimulation (NMES) combined with swallowing rehabilitation training on the healing effect and quality of life of stroke patients with dysphagia.

METHODS

The clinical data of 63 stroke patients admitted to the First Affiliated Hospital of Zhengzhou University from October 2019 to September 2020 were retrospectively analyzed. The included patients were divided into two groups according to different treatment plans: an observation group (n=33) treated with NMES combined with swallowing rehabilitation training, and a control group (n=30) treated by swallowing rehabilitation training alone. Before and after 2 courses of treatment, the Water swallow test, Functional Oral Intake Scale (FOIS), and MD Anderson Dysphagia Inventory (MDADI) were used to assess the swallowing function of patients in the two groups, and the National Institutes of Health Stroke Scale (NIHSS) was used to evaluate patients' neurological deficit; the SA7550 surface electromyogram (EMG) analysis system was applied to collect surface EMG, and the F113-5 medical X-ray TV system was used to detect the mobility of the hyoid-throat complex; the negative emotions of patients were assessed using the Hamilton Rating Scale for Depression (HAMD) before and after treatment, and the quality of life was evaluated by the Swallowing Quality of Life (SWAL-QOL) questionnaire; and the occurrence of adverse reactions during treatment was recorded and compared between the two groups.

RESULTS

There was no significant difference in swallowing function, duration of swallowing, maximum amplitude value, and hyoid-throat complex mobility between the two groups before treatment (P>0.05), nor were there any differences in the scores of FOIS, MDADI, NIHSS, HAMD, and SWAL-QOL before treatment (P>0.05). After treatment, however, the above indicators of both groups were significantly improved (P<0.05), and the improvements were more significant in the observation group compared with the control group (P<0.05). Moreover, the incidence of adverse reactions in both groups were relatively low without significant difference between groups (P>0.05).

CONCLUSION

NMES combined with swallowing rehabilitation training is effective in the treatment of swallowing dysfunction following stroke. It can effectively improve patients' swallowing function and quality of life, and relieve their negative emotions, with a high safety profile, which is worthy of clinical promotion.

The Effect and Dose-Response of Functional Electrical Stimulation Cycling Training on Spasticity in Individuals With Spinal Cord Injury: A Systematic Review With Meta-Analysis

Background: To investigate the effect and dose-response of functional electrical stimulation cycling (FES-cycling) training on spasticity in the individuals with spinal cord injury (SCI). Method: Five electronic databases [PubMed, Scopus, Medline (Proquest), Embase, and Cochrane Central Register of Controlled Trials (CENTRAL)] were searched before September 2021. The human trials and studies of English language were only included. Two authors independently reviewed and extracted the searched studies. The primary outcome measure was spasticity assessed by Modified Ashworth Scale or Ashworth Scale for lower limbs. The secondary outcome measures were walking abilities, such as 6 Min Walk Test (6MWT), Timed Up and Go (TUG), and lower limbs muscle strength (LEMS). A subgroup analysis was performed to investigate the efficacious threshold number of training sessions. A meta-regression analysis was used to examine the linear relationship between the training sessions and the effect on spasticity. Results: A total of 764 studies were identified. After screening, 12 selected studies were used for the qualitative synthesis, in which eight of them were quantitatively analyzed. Eight studies included ninety-nine subjects in total with SCI (male: female = 83:16). The time since injury was from less than 4 weeks to 17 years. The age ranged from 20 to 67 years. American Spinal Injury Association (ASIA) impairment level of the number of participants was 59 for ASIA A, 11 for ASIA B, 18 for ASIA C, and 11 for ASIA D. There were 43 subjects with tetraplegia and 56 subjects with paraplegia. Spasticity decreased significantly (95% CI = - 1.538 to - 0.182, p = 0.013) in favor of FES-cycling training. The walking ability and LEMS also improved significantly in favor of FES-cycling training. The subgroup analysis showed that spasticity decreased significantly only in more than 20 training sessions (95% CI = - 1.749 to - 0.149, p = 0.020). The meta-regression analysis showed training sessions and spasticity were not significantly associated (coefficient = - 0.0025, SE = 0.0129, p = 0.849, R ² analog = 0.37). Conclusion: Functional electrical stimulation-cycling training can improve spasticity, walking ability, and the strength of the lower limbs in the individuals with SCI. The number of training sessions is not linearly related to the decrease of spasticity. Twenty sessions of FES-cycling training are required to obtain the efficacy to decrease spasticity.

Efficacy of Electrical Stimulation-Augmented Virtual Reality Training in Improving Balance in Individuals with Incomplete Spinal Cord Injury: Study Protocol of a Randomized Controlled Trial

STUDY DESIGN

This study is a single-blind, parallel, three-group, and randomized controlled trial.

PURPOSE

This study aimed to investigate the effectiveness of electrical stimulation-augmented virtual reality training in improving balance in individuals with incomplete spinal cord injury (iSCI).

OVERVIEW OF LITERATURE

Individuals with iSCI often face significant balance and mobility impairments affecting their quality of life. Scientific studies focusing on standing balance training in the iSCI population are limited. Virtual reality-based balance training has shown positive results in several neurological populations. Electrical stimulation has also proved to be effective in improving voluntary muscle strength in partially paralyzed muscles after iSCI as well as promoting neuroplasticity.

METHODS

Forty-eight iSCI participants will be recruited based on the inclusion criteria. The participants will be randomly assigned to any of the three groups: virtual reality-based balance training along with the electrical stimulation group, virtual reality-based balance training along with sham stimulation group, or virtual reality-based balance training group. The intervention will be delivered as 60-minute sessions, thrice a week for 4 weeks.

RESULTS

The performance of the participants will be assessed using the lower extremity motor score, static and dynamic balance assessment using TechnoBody ProKin tilting platform and Berg Balance Scale, Walking Index for Spinal Cord Injury, and World Health Organization Quality of Life-BREF at pre-intervention, after 4 weeks post-intervention, and at 1-month follow-up.

CONCLUSIONS

The trial will provide new knowledge about the effectiveness of electrical stimulation-augmented virtual reality training in improving balance in individuals with iSCI. The study results will contribute to the design of better rehabilitation programs for individuals with iSCI.

Neuromuscular electrical stimulation for motor recovery in pediatric neurological conditions: a scoping review

AIM

To explore the breadth of pediatric neurological conditions for which neuromuscular electrical stimulation (NMES) has been studied.

METHOD

Databases (PubMed, Google Scholar, Scopus, and Embase) were searched from 2000 to 2020, using the search terms 'neuromuscular electrical stimulation' OR 'functional electrical stimulation' with at least one of the words 'pediatric OR child OR children OR adolescent', and without the words 'dysphagia OR implanted OR enuresis OR constipation'. Articles focused on adults or individuals with cerebral palsy (CP) were excluded.

RESULTS

Thirty-five studies met the inclusion criteria, with a total of 353 pediatric participants (293 unique participants; mean age 7y 4mo, range 1wk-38y). NMES was applied in a range of pediatric conditions other than CP, including stroke, spinal cord injury, myelomeningocele, scoliosis, congenital clubfoot, obstetric brachial plexus injury, genetic neuromuscular diseases, and other neuromuscular conditions causing weakness.

INTERPRETATION

All 35 studies concluded that NMES was well-tolerated and most studies suggested that NMES could augment traditional therapy methods to improve strength. Outcome measurements were heterogeneous. Further research on NMES with larger, randomized studies will help clarify its potential to improve physiology and mobility in pediatric patients with neuromuscular conditions. What this paper adds Neuromuscular electrical stimulation (NMES) appears to be tolerated by pediatric patients. NMES shows potential for augmenting recovery in pediatric patients with a range of rehabilitation needs.

Effects of functional electrical stimulation on muscle health after spinal cord injury

Spinal cord injury is a devastating condition interrupting voluntary movement and motor control. In response to unloading, skeletal muscle undergoes numerous adaptations, including rapid and profound atrophy, intramuscular fat accumulation, impaired muscular glucose metabolism and decreased force generation and muscle performance. Functional electrical stimulation (FES) involves electrically stimulating affected muscles to contract in a coordinated manner to create a functional movement or task. Effects of FES-cycling, rowing and resistance training on muscle health are described here. Briefly, FES-cycling and resistance training may slow muscle atrophy or facilitate muscle hypertrophy, and all modalities benefit muscle composition and performance to some extent. These interventions show promise as future rehabilitative tools after spinal cord injury.

Rehabilitation of the Canine Forelimb

The goal of rehabilitation is to restore function and mobility and reduce pain associated with chronic disease. In human medicine, physical therapy is standard of care for acute and chronic injuries and an integral component of postoperative recovery. Although there is a dearth of evidence-based veterinary medical studies in rehabilitation therapy and modalities for forelimb injuries in dogs, some extrapolation from human medicine can be made and applied. When developing a rehabilitation and therapeutic plan, the biomechanics of the affected limb and timeline of tissue healing of the target tissue and/or joint are important to consider.

Reduction in post-spinal cord injury spasticity by combination of peripheral nerve grafting and acidic fibroblast growth factor infusion in monkeys

OBJECTIVE

Spasticity is a frequent complication after spinal cord injury (SCI), but the existing therapies provide only limited relief and are associated with adverse reactions. Therefore, we aimed to develop a novel strategy to ameliorate the spasticity induced by SCI.

METHODS

This nonrandomized controlled study used a repeated measurement design. The study involved four monkeys, two of which served as controls and only underwent spinal cord hemisection surgery at the T8 spine level. The other two monkeys underwent transplantation of sural nerve segments into the injured sites and long-term infusion of acidic fibroblast growth factor (aFGF). All monkeys received postoperative exercise training and therapy.

RESULTS

The combined therapy substantially reduced the spasticity in leg muscle tone, patella tendon reflex, and fanning of toes. Although all monkeys showed spontaneous recovery of function over time, the recovery in the controls reached a plateau and started to decline after 11 weeks.

CONCLUSIONS

The combination of peripheral nerve grafting and aFGF infusion may serve as a complementary approach to reduce the signs of spasticity in patients with SCI.

Effects of Neuromuscular Electrical Stimulation Combined with Exercises versus an Exercise Program on the Physical Characteristics and Functions of the Elderly: A Randomized Controlled Trial

(1) Background-The application of neuromuscular electrical stimulation (NMES) combined with low-intensity exercise to the elderly can be more efficient than low-intensity exercise only in terms of delaying the loss of muscle mass. We aimed to assess the adjunct of NMES to low-intensity lower limb strengthening exercise to prevent falls in frail elderly for a relatively short period of 4 weeks. (2) Methods-Thirty elderly women aged 65 or above were randomly categorized into three groups: control group (CON, n = 8), exercise group (EX, n = 10), and NMES with exercise group (EX + NMES, n = 9). The exercise group took part in a lower limb strengthening exercise program for one hour three times a week for four weeks. Furthermore, the NMES with exercise group had added NMES stimulation when exercising. The limbs' muscle mass, body fat mass, calf circumference, grip force, five times sit-to-stand test, timed up-and-go test (TUG), one-leg stand test, and Y-balance test (YBT) were evaluated at baseline and 4 weeks after. (3) Results-Comparisons between the three groups showed that the TUG was significantly decreased and the YB was significantly increased in NMES with exercise group (p < 0.05). (4) Conclusions-These results suggested that a combination of NMES stimulation and exercises was more helpful in strengthening balance than exercises alone in the short term.

Omitting TMS component from paired associative stimulation with high-frequency PNS: A case series of tetraplegic patients

Objectives

Earlier studies have shown how chronic spinal cord injury (SCI) patients have benefitted from paired associative stimulation (PAS), consisting of high-frequency peripheral nerve stimulation (PNS) and high-intensity transcranial magnetic stimulation (TMS). Since high-frequency PNS is poorly characterized, its therapeutic effect without TMS should be evaluated. We tested the effect of PNS combined with motor imagery in chronic SCI patients using the same parameters of PNS as in earlier PAS-based studies that also used TMS.

Methods

Five patients with chronic incomplete SCI and tetraplegia received a 6-week treatment of PNS combined with motor imagery to the weaker upper limb. Patients were evaluated with Manual Muscle Testing (MMT), hand function tests (Box and block, grip and pinch strength dynamometry), and spasticity.

Results

There was no significant change in hand function tests or spasticity. MMT values improved significantly immediately after the PNS period (0.59 ± 0.17, p = 0.043) and in the 1-month follow-up visit (0.87 ± 0.18, p = 0.043). However, improvement of MMT values was weaker than in chronic tetraplegic patients in a corresponding PAS study that used identical PNS stimulation but also included the TMS component omitted here (Tolmacheva et al., 2019a, Clin Neurophysiol Pract).

Conclusions

The lack of effect on functional hand tests with the protocol presented here suggests that the synergistic effect of PNS and TMS components is essential for the full therapeutic effect previously observed with PAS intervention. The moderate improvement of the MMT score suggests the possible usefulness of PNS and motor imagery for some of those tetraplegic SCI patients who have contraindications to TMS.

Significance

These results add to the understanding of the PAS therapeutic mechanism by highlighting the importance of dual stimulation for achieving the full therapeutic effect of long-term PAS with a high-frequency PNS component.

A Scoping Review of Neuromuscular Electrical Stimulation to Improve Gait in Cerebral Palsy: The Arc of Progress and Future Strategies

Background: Neuromuscular deficits of children with spastic cerebral palsy (CP) limits mobility, due to muscle weakness, short muscle-tendon unit, spasticity, and impaired selective motor control. Surgical and pharmaceutical strategies have been partially effective but often cause further weakness. Neuromuscular electrical stimulation (NMES) is an evolving technology that can improve neuromuscular physiology, strength, and mobility. This review aims to identify gaps in knowledge to motivate future NMES research. Methods: Research publications from 1990- July 20th 2019 that investigated gait-specific NMES in CP were reviewed using the PubMed and Google Scholar databases. Results were filtered by the National Institute of Neurological Disorder and Stroke common data elements guidelines for CP. The Oxford Centre for Evidence Based Medicine guidelines were used to determine levels of evidence for each outcome. Gait-specific NMES research protocols and trends are described, with implications for future research. Results: Eighteen studies met inclusion criteria, reporting on 212 participants, 162 of whom received NMES while walking, average age of 9.8 years, GMFCS levels I-III. Studies included 4 randomized control trials, 9 cohort studies and 5 case studies. A historical trend emerged that began with experimental multi-channel NMES device development, followed by the commercial development of single-channel devices with inertial sensor-based gait event detection to facilitate ankle dorsiflexion in swing phase. This research reported strong evidence demonstrating improved ankle dorsiflexion kinematics in swing and at initial contact. Improved walking speed, step length, and muscle volume were also reported. However, improvements in global walking scores were not consistently found, motivating a recent return to investigating multi-channel gait-specific NMES applications. Conclusions: Research on single-channel gait-specific NMES found that it improved ankle motion in swing but was insufficient to address more complex gait abnormalities common in CP, such as flexed-knee and stiff-knee gait. Early evidence indicates that multi-channel gait-specific NMES may improve gait patterns in CP, however significantly more research is needed. The conclusions of this review are highly limited by the low level of evidence of the studies available. This review provides a historical record of past work and a technical context, with implications for future research on gait-specific NMES to improve walking patterns and mobility in CP.

Overview of Systematic Reviews of Aerobic Fitness and Muscle Strength Training after Spinal Cord Injury

The number of systematic reviews on the effects of exercise on aerobic fitness and muscle strength in people with spinal cord injury (SCI) has recently increased. However, the results of some of these reviews are inconclusive or inconsistent. To strengthen recommendations, this overview was undertaken to assimilate evidence about the effectiveness of different types of physical activities, exercises, and therapeutic interventions for improving aerobic fitness and muscle strength in people with SCI. Cochrane Overview of reviews methods were adopted to undertake this overview. An online search was conducted in August 2018 on eight databases based on predefined search criteria. Potential systematic reviews were screened, selected, and assessed on methodological quality by two independent authors, and discussed and resolved with a third author, when necessary. Only systematic reviews published in the English language were included. The protocol was registered on PROSPERO. Overall, 16 systematic reviews were included (aerobic fitness, n = 10; muscle strength, n = 15). For all 16 reviews, the quality of evidence was rated as "critically low." Despite low evidence, this overview strengthens the existing guidelines for people with SCI, providing specific advice on exercise domains (types, intensities, frequency, and duration) for improving aerobic fitness and muscle strength. The evidence from this overview suggests that ergometry training with/without additional therapeutic interventions (20 min, moderate to vigorous intensity, twice weekly for 6 weeks) may improve aerobic fitness; similarly, resistance training with/without additional therapeutic interventions (three sets of 8-10 repetitions, moderate to vigorous intensity, twice weekly for 6 weeks) may improve muscle strength.

Early Cyclical Neuromuscular Electrical Stimulation Improves Strength and Trophism by Akt Pathway Signaling in Partially Paralyzed Biceps Muscle After Spinal Cord Injury in Rats

BACKGROUND

Electrical stimulation is often used to treat weakness in people with spinal cord injury (SCI); however its efficacy for increasing strength and trophism is weak, and the mechanisms underlying the therapeutic benefits are unknown.

OBJECTIVE

The purpose of this study was to analyze the effects of neuromuscular electrical stimulation (NMES) on muscle function, trophism, and the Akt pathway signaling involved in muscular plasticity after incomplete SCI in rats.

DESIGN

This was an experimental study.

METHODS

Twenty-one adult female Wistar rats were divided into sham, SCI, and SCI plus NMES groups. In injured animals, SCI hemisection was induced by a surgical procedure at the C5-C7 level. The 5-week NMES protocol consisted of biceps brachii muscle stimulation 5 times per week, initiated 48 h after injury. Forepaw function and strength, biceps muscle trophism, and the expression of phosphorylated Akt, p70S6K, and GSK-3ß cellular anabolic pathway markers in stimulated muscle tissue were assessed.

RESULTS

There was an increase in bicep muscle strength in the NMES group compared with the untreated SCI group, from postoperative day 21 until the end of the evaluation period. Also, there was an increase in muscle trophism in the NMES group compared with the SCI group. Forelimb function gradually recovered in both the SCI group and the NMES group, with no differences between them. Regarding muscle protein expression, the NMES group had higher values for phospho-Akt, phospho-p70S6K, and phospho-GSK-3ß than did the SCI group.

LIMITATIONS

The experimental findings were limited to an animal model of incomplete SCI and may not be fully generalizable to humans.

CONCLUSIONS

Early cyclical NMES therapy was shown to increase muscle strength and induce hypertrophy after incomplete SCI in a rat model, probably by increasing phospho-Akt, phospho-p70S6K, and phospho-GSK-3ß signaling protein synthesis.