When the whole is greater than the sum of its parts: a scoping review of activity-based therapy paired with spinal cord stimulation following spinal cord injury

Abstract

Spinal cord injuries (SCI) result in both motor and autonomic impairments, which can negatively affect independence and quality of life and increase morbidity and mortality. Despite emerging evidence supporting the benefits of activity-based training and spinal cord stimulation as two distinct interventions for sensorimotor and autonomic recovery, the combined effects of these modalities are currently uncertain. This scoping review evaluated the effectiveness of paired interventions (exercise + spinal neuromodulation) for improving sensorimotor and autonomic functions in individuals with SCI. Four electronic databases were searched for peer-reviewed manuscripts (Medline, Embase, CINAHL and EI-compedex Engineering Village) and data were independently extracted by two reviewers using pre-established extraction tables. A total of 15 studies representing 79 participants were included in the review, of which 73% were conducted within the last five years. Only two of the studies were randomized controlled studies, while the other 13 studies were case or case-series designs. Compared to activity-based training alone, spinal cord stimulation combined with activity-based training improved walking and voluntary muscle activation, and augmented improvements in lower urinary tract, bowel, resting metabolic rate, peak oxygen consumption, and thermoregulatory function. Spinal neuromodulation in combination with use-dependent therapies may provide greater neurorecovery and induce long-term benefits for both motor and autonomic function beyond the capacity of traditional activity-based therapies. However, evidence for combinational approaches is limited and there is no consensus for outcome measures or optimal protocol parameters, including stimulation settings. Future large-scale randomized trials into paired interventions are warranted to further investigate these preliminary findings.

REPORT-SCS: minimum reporting standards for spinal cord stimulation studies in spinal cord injury

“…We used a Delphi approach to identify guideline items and obtain the expert panel's level of agreement on the items put forth [50,51]. Guideline items were recommended by the expert panel, identified from previously published literature reviews that highlighted insufficiencies in the reporting of stimulation parameters for experiments utilizing electrical SCS following SCI [31,32,34,[37][38][39]. We also examined resources for developing minimal reporting guidelines [42][43][44][45][46][47][48]52], such as the TIDieR checklist (i.e.…”

“…From the late 1980s to mid-2010s, roughly 1-3 articles per year were published on the use of SCS for managing SCI-related dysfunctions other than pain. Currently, over 20 articles are being published per year, with this number expected to grow [31,33,34]. This is validated by the fact that as of September 2023, there are 125 actively recruiting SCS clinical trials for SCI on clinicaltrials.gov.…”

“…Recent reviews on the use of epidural [37] and transcutaneous [38] SCS to improve motor function following SCI indicated that 18/18 and 21/25 articles, respectively, showed poor methodological quality. Small sample sizes, selection bias, inadequate reporting of adverse events and safety precautions taken to minimize risk, and limited validation of the outcome measures were common reasons for reduced quality across studies [31,34,[37][38][39]. Unstandardized reporting of outcomes, SCS parameters, and terminology are common in both pre-clinical [40] and clinical studies [31,34,37,38].…”

“…Small sample sizes, selection bias, inadequate reporting of adverse events and safety precautions taken to minimize risk, and limited validation of the outcome measures were common reasons for reduced quality across studies [31,34,[37][38][39]. Unstandardized reporting of outcomes, SCS parameters, and terminology are common in both pre-clinical [40] and clinical studies [31,34,37,38]. This limits the ability to interpret results, reproduce published findings, and contributes to the delay in translation of these experimental therapies to clinical practice and standard of care.…”

Motor and autonomic concomitant health improvements with neuromodulation and exercise (MACHINE) training: a randomised controlled trial in individuals with spinal cord injury

“…Pairing LT with TSCS may further enhance the beneficial effect of each independent intervention, by combining task‐specific training together with plasticity‐augmenting stimulation 33 39. However, the outcome of the combination of electrotherapeutics and rehabilitative training on individuals with SCI needs to be further explored.…”