Activity-Based Locomotor Training with Spinal Stimulation: A New Frontier for Pediatric SCI

We're constantly on the lookout for new ways to help our pediatric patients with spinal cord injury (SCI) not just adapt, but truly recover. That's why we were so interested in a recent pilot study that explored the combination of two powerful modalities: activity-based locomotor training (AB-LT) and non-invasive transcutaneous spinal cord stimulation (scTS). This study, while small, offers a glimpse into a future where we can potentially enhance neuroplasticity and achieve greater functional gains for these kids. For years, we've known that the developing nervous system of a child with SCI is a double-edged sword. On one hand, their immaturity puts them at a high risk for secondary complications like scoliosis. On the other, it also presents a unique window of opportunity for recovery. Activity-based therapies, like the locomotor training we do in the clinic, are designed to tap into this potential by providing the central nervous system with the sensory input it needs to relearn motor tasks. We've seen firsthand how AB-LT can improve trunk control, which is so foundational for everything from sitting balance to walking. This pilot study took things a step further by adding scTS to the mix. The idea here is that by delivering a low-level electrical current to the spinal cord, we can essentially “prime” the neural circuits involved in movement, making them more receptive to the effects of the locomotor training. The study included three boys with chronic SCI who had already completed at least 60 sessions of AB-LT. They then underwent an additional 19 to 64 sessions of AB-LT, this time with the addition of scTS. The intervention itself was quite comprehensive. Each session involved a period of sitting with scTS to optimize the stimulation parameters, followed by locomotor training on a treadmill and overground. The treadmill training involved partial body weight support and manual facilitation from therapists to promote proper stepping kinematics. The overground training challenged the participants' trunk control in a variety of sitting, standing, and stepping activities. The scTS was applied using electrodes placed on the skin over the thoracic and lumbar spine, with a 10 kHz current delivered in short bursts. The results were really encouraging. All three participants showed measurable improvements in trunk control, both in quiet sitting and when their balance was challenged. They were better able to maintain an upright posture and showed increased muscle activation in their trunk, even below the level of their injury. This suggests that the combination of AB-LT and scTS was indeed promoting neural remodeling and enhancing the neuromuscular capacity for trunk control. Of course, with any new intervention, safety is a top concern. The researchers in this study were very diligent about monitoring for adverse effects. While there were a few instances of autonomic dysreflexia, skin redness, and headaches, the vast majority of the sessions (88.5%) were completed without any issues. This is a crucial finding, as it suggests that with careful monitoring, this combined therapy can be safely implemented in a clinical setting. So, what does this all mean for us as clinicians? This pilot study provides the first piece of evidence that combining AB-LT with scTS is not only safe and feasible for children with SCI, but also has the potential to be more effective than AB-LT alone. It's a promising step forward in our quest to maximize recovery for these young patients. While we need larger, controlled studies to confirm these findings and optimize the treatment protocols, this research gives us a solid foundation to build upon. It's an exciting time to be in the field of pediatric neurorehabilitation, and we're eager to see how this innovative approach will continue to evolve and benefit the children we serve.