Lucas Kathryn, Singh Goutam, Alvarado Luis R, King Molly, Stepp Nicole, Parikh Parth, Ugiliweneza Beatrice, Gerasimenko Yury, Behrman Andrea L
Kentucky Spinal Cord Injury Research Center, Louisville, KY 40202, USA.
Department of Neurological Surgery, University of Louisville, KY 40202, USA.
Brain. 2025 Apr 4. doi: 10.1093/brain/awaf115.
Paralysis is assumed permanent in persons with motor-complete spinal cord injury (SCI). However, spinal epidural stimulation combined with activity-based locomotor training (ABLT) and cognitive intent enabled two adults with motor-complete SCI to walk with a walker. Transcutaneous spinal stimulation (scTS), also capable of promoting a cyclic step-like pattern, might be a viable alternative in children with SCI. These findings prompted our investigation into multimodal neuromodulation training using ABLT (enhancing afferent input), spinal stimulation (scTS), and descending (intent) drive to restore voluntary stepping in children with chronic motor-complete SCI. Five non-ambulatory children (9.6 ± 2.5 years old, 3F, 4 thoracic/1 cervical injury) with chronic (>1 year, 5.2 ± 2.5 years), complete SCI underwent 60 sessions of combined ABLT and scTS training with cognitive intent to step and returned for a 3 to 6-month follow-up. During the first training session in a gravity-neutral position, all five children (5/5) made small reciprocal cycles of the hips/knees in a flexion/extension step-like pattern with stimulation, with increased excursion at session 20 for 5/5 children (right hip excursion increased from 10.1 ± 15.1 to 25.9 ± 21.3 degrees and right knee excursion increased from 9.3 ± 13.9 to 39.6 ± 29.2 degrees, p = 0.02). The children stepped overground at session 50 (P15), 60 (P34), and 20 (P32, P14, P240), voluntarily initiating and alternating left/right leg swings on the treadmill and overground with and without scTS. Three to six months post-training, all children maintained the capacity to step. The parents and children reported unanticipated improvements in sensation, bladder function, proprioception, assist to stand, transfers, and dressing. In children with chronic, motor-complete SCI, multimodal neuromodulation training can potentiate the intrinsic stepping capacity of the spinal locomotor centers to enable voluntary stepping. Remarkably, these enhancements are durable and observed even in the absence of spinal stimulation.
对于运动完全性脊髓损伤（SCI）患者，通常认为瘫痪是永久性的。然而，脊髓硬膜外刺激联合基于活动的运动训练（ABLT）以及认知意图，使两名运动完全性SCI成年患者能够借助助行器行走。经皮脊髓刺激（scTS）也能够促进周期性的类似步态模式，对于SCI儿童可能是一种可行的替代方法。这些发现促使我们开展一项关于多模式神经调节训练的研究，该训练采用ABLT（增强传入输入）、脊髓刺激（scTS）以及下行（意图）驱动，以恢复慢性运动完全性SCI儿童的自主步态。五名非步行儿童（年龄9.6±2.5岁，3名女性，4例胸椎损伤/1例颈椎损伤），患有慢性（>1年，5.2±2.5年）、完全性SCI，接受了60次ABLT和scTS联合训练，并带有迈步的认知意图，之后返回进行3至6个月的随访。在首次处于重力中立位的训练 session 中，所有五名儿童（5/5）在刺激下以屈伸类似步态模式进行了小幅度的髋部/膝部交替循环，到第20次session时，所有5名儿童（5/5）的活动范围都有所增加（右髋活动范围从10.1±15.1度增加到25.9±21.3度，右膝活动范围从9.3±13.9度增加到39.6±29.2度，p = 0.02）。在第50次session（P15）、60次session（P34）以及20次session（P32、P14、P240）时，儿童在地面上行走，在跑步机上以及地面上，无论有无scTS，都能自主启动并交替左右腿摆动。训练后3至6个月，所有儿童都保持了迈步能力。家长和儿童报告感觉、膀胱功能、本体感觉、站立辅助、转移以及穿衣方面出现了意外改善。对于慢性运动完全性SCI儿童，多模式神经调节训练可以增强脊髓运动中枢的内在步态能力，从而实现自主步态。值得注意的是，即使在没有脊髓刺激的情况下，这些改善仍然持久。
