Augmenting Therapy with Transcutaneous Electrical Spinal Cord Stimulation (TSCS) to Improve Walking Function in an Individual with Motor-Incomplete Spinal Cord Injury: A Case Report
McHugh L, Miller A
Kennedy Krieger Institute, Baltimore, MD, USA
TSCS is a non-invasive mechanism to enhance excitation of spinal neural circuitry and represents a promising supplement to existing physical therapy programs. Evidence of decreased spasticity and initiation of step-like movements has been demonstrated.1,2,3,4 In response to a single session of TSCS, involuntary step-like movements can be induced immediately upon application of stimulation. EMG has also shown a gradual increase in magnitude of step-like movements when TSCS is maintained for an increased amount of time.3,4,5 This increase in spinal excitability via TSCS may augment traditional rehabilitation therapies and maximize functional outcomes with greater durability than other interventions.2,4. The objective of this case study is to describe the impact of concurrent TSCS and gait training on walking function in a subject with iSCI.
2. Case Presentation and Timeline.
We present a single case review of a 24 y/o female, 2 years post injury, with T8 AISA Impairment Scale (AIS) C spinal cord injury. She presented with lower extremity muscle strength in gravity eliminated positions; right lower extremity being stronger than left lower extremity. She also demonstrated the ability to ambulate short distances with supervision, left HKAFO, right AFO and rolling walker. At initial assessment, she had a Walking Index for Spinal Cord Injury II of 9 and a gait speed of 0.33 m/s as measured by 10M Walk Test.
3. Therapeutic Focus and Assessment.
TSCS was applied using a 2 x 4 inch oval electrode placed midline on the skin between spinous process T11 –T12 as a cathode and two 3 x 5 inch rectangular electrodes placed symmetrically on the skin over the lower abdomen as anodes. A symmetrical biphasic rectangular waveform, at 50Hz and 1 millisecond, was used to provide continuous stimulation for 30 minutes. Subject participated in an eight-week program of gait training with TSCS and was assessed with clinically relevant outcome measures. The following therapeutic interventions were paired with TSCS: intersegmental task specific movement in gravity eliminated positions, standing balance, gait training using body weight support and over ground gait training.
4. Follow-up and Results.
The subject tolerated application of TSCS without adverse response. She participated in 24 sessions without interruption. Her walking speed, as measured by the 10 Meter Walk Test, improved by 0.45m/s (30.53s to 12.91s). Scores on the 6-Minute Walk Test improved from 89.6m to 162m, indicating enhanced walking endurance. Subject advanced her assistive device over the duration of the study to improve her Walking Index for Spinal Cord Injury II score from 9 to 12. All outcome measure improvements exceed the established MCID for iSCI. Subject reported subjective improvement in bowel and bladder function and sensation.
These observations suggest that TSCS in combination with activity-based gait training may be useful to improve functional outcomes for patients with iSCI. TSCS deserves further study as a mechanism to augment functional recovery following spinal pathology. Future research should include evaluations beyond gait speed and endurance, to include step metrics, sensation, and bowel and bladder function.
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