While priming is most often thought of as a strategy for modulating neural excitability to facilitate voluntary motor control, priming stimulation can also be utilized to target spinal reflex excitability. In this application, priming can be used to modulate the involuntary motor output that often follows central nervous system injury. Individuals with spinal cord injury (SCI) often experience spasticity, for which antispasmodic medications are the most common treatment. Physical therapeutic/electroceutic interventions offer an alternative treatment for spasticity, without the deleterious side effects that can accompany pharmacological interventions. While studies of physical therapeutic/electroceutic interventions have been published, a systematic comparison of these approaches has not been performed. The purpose of this study was to compare four non-pharmacological interventions to a sham-control intervention to assess their efficacy for spasticity reduction. Participants were individuals (n = 10) with chronic SCI (≥1 year) who exhibited stretch-induced quadriceps spasticity. Spasticity was quantified using the pendulum test before and at two time points after (immediate, 45 min delayed) each of four different physical therapeutic/electroceutic interventions, plus a sham-control intervention. Interventions included stretching, cyclic passive movement (CPM), transcutaneous spinal cord stimulation (tcSCS), and transcranial direct current stimulation (tDCS). The sham-control intervention consisted of a brief ramp-up and ramp-down of knee and ankle stimulation while reclined with legs extended. The order of interventions was randomized, and each was tested on a separate day with at least 48 h between sessions. Compared to the sham-control intervention, stretching, CPM, and tcSCS were associated with a significantly greater reduction in spasticity immediately after treatment. While the immediate effect was largest for stretching, the reduction persisted for 45 min only for the CPM and tcSCS interventions. tDCS had no immediate or delayed effects on spasticity when compared to sham-control. Interestingly, the sham-control intervention was associated with significant within-session increases in spasticity, indicating that spasticity increases with immobility. These findings suggest that stretching, CPM, and tcSCS are viable non-pharmacological alternatives for reducing spasticity, and that CPM and tcSCS have prolonged effects. Given that the observed effects were from a single-session intervention, future studies should determine the most efficacious dosing and timing strategies.

Locomotor training (LT) is intended to improve walking function and can also reduce spasticity in motor-incomplete spinal cord injury (MISCI). Transcutaneous spinal stimulation (TSS) also influences these outcomes. We assessed feasibility and preliminary efficacy of combined LT + TSS during inpatient rehabilitation in a randomized, sham-controlled, pragmatic study. Eighteen individuals with subacute MISCI (2–6 months post-SCI) were enrolled and randomly assigned to the LT + TSS or the LT + TSSsham intervention group. Participants completed a 4-week program consisting of a 2-week wash-in period (LT only) then a 2-week intervention period (LT + TSS or LT + TSSsham). Before and after each 2-week period, walking (10 m walk test, 2-min walk test, step length asymmetry) and spasticity (pendulum test, clonus drop test, modified spinal cord injury—spasticity evaluation tool) were assessed. Sixteen participants completed the study. Both groups improved in walking speed and distance. While there were no significant between-groups differences, the LT + TSS group had significant improvements in walking outcomes following the intervention period; conversely, improvements in the LT + TSSsham group were not significant. Neither group had significant changes in spasticity, and the large amount of variability in spasticity may have obscured ability to observe change in these measures. TSS is a feasible adjunct to LT in the subacute stage of SCI and may have potential to augment training-related improvements in walking outcomes.

NCT02340910 (assigned 01/19/2015).

Control of muscles about the ankle joint is an important component of locomotion and balance that is negatively impacted by spinal cord injury (SCI). Volitional control of the ankle dorsiflexors (DF) is impaired by damage to pathways descending from supraspinal centers. Concurrently, spasticity arising from disrupted organization of spinal reflex circuits, further erodes control. The association between neurophysiological changes (corticospinal and spinal) with volitional ankle control (VAC) and spasticity remains unclear. The goal of this scoping review was to synthesize what is known about how changes in corticospinal transmission and spinal reflex excitability contribute to disrupted ankle control after SCI. We followed published guidelines for conducting a scoping review, appraising studies that contained a measure of corticospinal transmission and/or spinal reflex excitability paired with a measure of VAC and/or spasticity. We examined studies for evidence of a relationship between neurophysiological measures (either corticospinal tract transmission or spinal reflex excitability) with VAC and/or spasticity. Of 1,538 records identified, 17 studies were included in the review. Ten of 17 studies investigated spinal reflex excitability, while 7/17 assessed corticospinal tract transmission. Four of the 10 spinal reflex studies examined VAC, while 9/10 examined ankle spasticity. The corticospinal tract transmission studies examined only VAC. While current evidence suggests there is a relationship between neurophysiological measures and ankle function after SCI, more studies are needed. Understanding the relationship between neurophysiology and ankle function is important for advancing therapeutic outcomes after SCI. Future studies to capture an array of corticospinal, spinal, and functional measures are warranted.