Transcutaneous electrical stimulation of the spinal cord: A noninvasive tool for the activation of stepping pattern generators in humans

A new method for the activation of spinal locomotor networks (SLN) in humans by transcutaneous electrical spinal cord stimulation (tESCS) has been described. The tESCS applied in the region of the T11-T12 vertebrae with a frequency of 5?C40 Hz elicited involuntary step-like movements in healthy subjects with their legs suspended in a gravity-neutral position. The amplitude of evoked step-like movements increased with increasing tESCS frequency. The frequency of evoked step-like movements did not depend on the frequency of tESCS. It was shown that the hip, knee, and ankle joints were involved in the evoked movements. It has been suggested that tESCS activates the SPG (SLN) through in part, via the dorsal roots that enter the spinal cord. tESCS can be used as a noninvasive method in rehabilitation of spinal pathology.     

Sensorimotor regulation of movements: Novel strategies for the recovery of mobility

A series of observations have provided important insight into properties of the spinal as well as supraspinal circuitries that control posture and movement. We have demonstrated that spinal rats can regain full weight-bearing standing and stepping over a range of speeds and directions with the aid of electrically enabling motor control (eEmc), pharmacological modulation (fEmc), and training [1, 2]. Also, we have reported that voluntary control movements of individual joints and limbs can be regained after complete paralysis in humans [3, 4]. However, the ability to generate significant levels of voluntary weight-bearing stepping with or without epidural spinal cord stimulation remains limited. Herein we introduce a novel method of painless transcutaneous electrical enabling motor control (pcEmc) and sensory enabling motor control (sEmc) strategy to neuromodulate the physiological state of the spinal cord. We have found that a combination of a novel non-invasive transcutaneous spinal cord stimulation and sensory-motor stimulation of leg mechanoreceptors can modulate the spinal locomotor circuitry to state that enables voluntary rhythmic locomotor movements.     

Significance of peripheral feedback in stepping movement generation under epideral spinal cord stimulation

In acute experiments on decerebrated and spinalized cats, the role of peripheral afferent input from hindlimbs in stepping patterns formation under epidural spinal cord stimulation (ESCS), was investigated. The hindlimb muscles' electromyographic activity and kinematic parameters of evoked stepping were analyzed. It has been shown that epidural stimulation (20-100 microA, 5 Hz) of L4-L5 spine segments induced coordinated stepping on the treadmill belt. In conditions of weight-bearing support (stopped treadmill, hindlimbs lifted above the treadmill), the stepping rhythmic was unstable, stepping cycle period and its internal structure having changed as well. With increased speed of locomotion the stepping frequency increased due to the duration of the support phase decreasing. Forward stepping could be reversed to backward stepping by changing the direction of the treadmill belt movement. In 2-4 hours after complete spinal transection (T8-T9), the epidural stimulation elicited stepping movements on a moving treadmill only. It was found that the influence of peripheral feedback on initiation of the stepping after spinalization increased. Peripheral feedback seems to play a major role in determining the fundamental features of motor output during the ESCS.     

Noninvasive method to control the human spinal locomotor systems

The mechanism of interactions between receptor activation in the musculoskeletal system and stimulation of the spinal cord in the regulation of locomotor behavior was studied in healthy subjects. Afferent stimulation was tested for effect on the patterns of stepping movements induced by percutaneous stimulation of the spinal cord. A combination of percutaneous spinal cord stimulation and vibratory stimulation was shown to increase the amplitude of leg movements. It was demonstrated that vibratory stimulation of limb muscles at a frequency of less than 30 Hz can be used to control involuntary movements elicited by noninvasive stimulation of the spinal cord.     

Mechanisms of stepping rhythm formation in decerebrated and chronic spinal cats under epidural stimulation

A study was made of the stepping pattern formation in decerebrated and in chronic spinal cats during epidural stimulation (ES). The hindlimb stepping performance depended on the parameters of ES and afferent input. At non-optimal ES parameters, no stepping was induced, only muscle reflexes followed the stimulation rhythm. Optimized ES (3–5 Hz, 50–100 μA for decerebrated and 20–30 Hz, 150–250 μA for spinal cats) evoked coordinated stepping movements at a natural rate (0.8–1 Hz) accompanied by electromyographic burst activity of the corresponding muscles. In decerebrated cats, the bursts are formed owing to modulation of early responses and the late polysynaptic activity. In chronic spinal cats, this process is mainly due to amplitude modulation of the early responses. Formation of the stepping pattern in decerebrated cats involves spinal interneurons responsible for the polysynaptic activity, which allows its correction based on processing the afferent signals. Activation of this system in chronic spinal cats can be realized by afferent stimulation alone, without ES.     

Locomotion induced by epidural stimulation in a decerebrated cat after spinal cord injury

The effect of partial and complete spinal cord transection (Th7–Th8) on locomotor activity evoked in decerebrated cats by electrical epidural stimulation (segment L5, 80–100 μA, 0.5 ms at 5 Hz) has been investigated. Transection of dorsal columns did not substantially influence the locomotion. Disruption of the ventral spinal quadrant resulted in deterioration and instability of the locomotor rhythm. Injury to lateral or medial descending motor systems led to redistribution of the tone in antagonist muscles. Locomotion could be evoked by epidural stimulation within 20 h after complete transection of the spinal cord. The restoration of polysynaptic components in EMG responses correlated with recovery of the stepping function. The data obtained confirm that initiation of locomotion under epidural stimulation is caused by direct action on intraspinal systems responsible for locomotor regulation. With intact or partially injured spinal cord, this effect is under the influence of supraspinal motor systems correcting and stabilizing the evoked locomotor pattern.     

Epidural recordings of electrical events produced in the spinal cord by segmental, ascending and descending volleys

Epidural electrodes implanted for a percutaneous trial of therapeutic spinal cord stimulation were used to record electrical events evoked by the stimulation of peripheral nerves or of the spinal cord itself. The data collected in patients with no neurological deficit were analyzed in order (1) to check the consistency between epidural and surface recordings, (2) to get information on the genesis of such potentials, and (3) to demonstrate the feasibility of complex neurophysiological studies by means of epidural electrodes. Spinal cord potentials evoked by segmental volleys were recorded at cervical levels with the recording electrodes anterior, lateral and posterior to the spinal cord. The refractory period of the evoked potentials has been studied as well. Responses to stimulation of the tibial nerve were obtained at T11-12 vertebral level with posterior epidural electrodes. Segmental cervical potentials were characterized by a P10, N11, N13/P13 followed by a slow positivity/negativity. A response of similar waveform, but with different peak latencies, was recorded at segmental levels following tibial nerve stimulation. Such a response showed an increasing number of spikes while ascending along the spinal cord. Maximum conduction velocities in the cord were between 65 and 85 m/s. Our epidural recordings are similar to those obtained from the skin, but with a greater amplitude and waveform resolution. Furthermore, the use of epidural electrodes made it feasible to perform complex examinations of sensory function (i.e., the study of orthodromic and antidromic conduction along the dorsal cord and of the influence of a single dorsal cord volley on the segmental cervical potential). Finally, the genesis of the potentials recorded is discussed.     

Distribution of lumbar spinal evoked potentials and their correlation with stimulation-induced paresthesiae

In 7 awake patients with neuropathic lower extremity pain, spinal somatosensory evoked potentials (SEP) were elicited from the non-painful leg by electrical stimulation of the peroneal nerve and mechanical stimulation of the hallux ball. Recording was made epidurally in the thoraco-lumbar region by means of an electrode temporarily inserted for trial of pain-suppressing stimulation.In response to peroneal nerve stimulation, two major SEP complexes were found. The first complex consisted, as has been described earlier, of an initial positivity (P12), a spike-like negativity (N14), a slow negativity (N16) and a slow positivity (P23). The second complex consisted of a slow biphasic wave, conceivably mediated by a supraspinal loop. Both complexes had a similar longitudinal distribution with amplitude maxima at the T12 vertebral body.The SEP evoked by mechanical hallux ball stimulation had a relatively small amplitude, and there was no significant second complex. The relationship between stimulus intensity and SEP amplitude was negatively accelerating.The longitudinal distribution of spinal SEP was compated with the somatotopic distribution of paresthesiae induced by stimulation through the epidural electrode. It was found that stimulation applied at the level of maximal SEP generally induced paresthesiae in the corresponding peripheral region. Therefore, spinal SEP may be used as a guide for optimal positioning of a spinal electrode for therapeutic stimulation when implanted under general anesthesia.An attempt was made to record the antidromic potential in the peroneal nerve elicited from the dorsal columns by epidural stimulation. The antidromic response was, however, very sensitive to minimal changes of stimulus strength and body position of the patient, and was also contaminated by simultaneously evoked muscular reflex potentials.Thus, peripheral responses evoked by epidural stimulation appeared too unreliable to be useful for the permanent implantation of a spinal electrode for therapeutic stimulation.     

Limb movements generated by stimulating muscle,nerve and spinal cord

We have compared the movements generated by stimulation of muscle, nerve, spinal roots and spinal cord in anesthetized, decerebrate and spinalized cats. Each method produced a full range of movements of the cat's hind limb in the sagittal plane against a spring load, except for stimulation of the roots. Stimulation of the dorsal roots produced movements that were mainly up and forward, whereas stimulation of the ventral roots produced complementary movements (down and backward). Results from stimulation in the intermediate areas of the spinal cord were compared to predictions of the "movement primitives" hypothesis. We could not confirm that the directions were independent of stimulus amplitude or the state of descending inputs. Pros and cons of stimulating at some sites were provisionally considered for the reliable control of limb movements with functional electrical stimulation (FES) in clinical conditions.     

Spinal tracts producing slow components of spinal cord potentials evoked by descending volleys in man

Slow negative (N) and slow positive (P) waves are frequently produced in the posterior epidural space at the lumbosacral enlargement by epidural stimulation of the rostral part of human spinal cord. The production of these slow potentials are thought to be responsible for analgesia at the stimulated segment as well as below that level. In order to define the spinal tract which mediates these slow potentials, we stimulated directly or from the epidural space the dorsal, dorsolateral, lateral and ventral columns at the cervical or thoracic level, and epidurally recorded spinal cord potentials (des.SCPs) at the lumbosacral enlargement in 7 patients who underwent spine or spinal cord surgery. The des.SCPs recorded in the lumbosacral enlargement consisted of polyphasic spike potentials followed by slow N and P waves. At a near threshold level of stimulus intensity the slow N and P potentials were consistently elicited only by stimulation of the dorsal column. The slow waves were also produced by intense stimulation of other tracts, but remained significantly (P < 0.05−P <0.01) smaller than those evoked by dorsal column stimulation when compared at the same stimulus intensity. Moreover, the slow P wave could not be elicited even by intense stimulation (10 times the threshold strength for the initial spike potentials) of the ventral column. Thus, the results suggest that the slow N and P waves are mostly mediated by the antidromic impulses descending through the dorsal column.     

Features of stepping pattern formation in decerebrated cats under epidural spinal cord stimulation

The mechanisms of stepping pattern formation initiated by epidural spinal cord stimulation in decerebrated cats, were investigated. It is shown that the ability to produce the stepping pattern involve the L3-L5 segments. In flexor muscle, the formation of stepping pattern under optimal stimulation frequency (5-10 Hz) of these segments is provided by polysynaptic activity with the latency 80-110 ms. In extensor muscle, this process is realized through interaction of monosynaptic reflex and polysynaptic activity. The stepping pattern under epidural stimulation is determined by spinal structures with modulation influence of the peripheral feedback.     

Enhancement of voluntary motor function following spinal cord stimulation--case study

One patient with an incomplete traumatic myelopathy underwent epidural spinal cord stimulation for the management of severe intractable spasms, which were abolished by the stimulation. After several months of stimulation, the patient regained some voluntary motor function in the lower extremities. Voluntary motor control of the left quadriceps was present only when spinal cord stimulation was activated and stopped immediately after it was turned off. The effects could be consistently reproduced. EMG polygraphic recordings confirmed the results.     

Movements generated by intraspinal microstimulation in the intermediate gray matter of the anesthetized, decerebrate, and spinal cat

The intermediate laminae of the lumbosacral spinal cord are suggested to contain a small number of specialized neuronal circuits that form the basic elements of movement construction ("movement primitives"). Our aim was to study the properties and state dependence of these hypothesized circuits in comparison with movements elicited by direct nerve or muscle stimulation. Microwires for intraspinal microstimulation (ISMS) were implanted in intermediate laminae throughout the lumbosacral enlargement. Movement vectors evoked by ISMS were compared with those evoked by stimulation through muscle and nerve electrodes in cats that were anesthetized, then decerebrated, and finally spinalized. Similar movements could be evoked under anesthesia by ISMS and nerve and muscle stimulation, and these covered the full work space of the limb. ISMS-evoked movements were associated with the actions of nearby motoneuron pools. However, after decerebration and spinalization, ISMS-evoked movements were dominated by flexion, with few extensor movements. This indicates that the outputs of neuronal networks in the intermediate laminae depend significantly on descending input and on the state of the spinal cord. Frequently, the outputs also depended on stimulus intensity. These experiments suggest that interneuronal circuits in the intermediate and ventral regions of the spinal cord overlap and their function may be to process reflex and descending activity in a flexible manner for the activation of nearby motoneuron pools.     

Response of external inspiration to the movements induced by transcutaneous spinal cord stimulation

The dynamic of the parameters of lung ventilation and gas exchange have been studied in 10 young male subjects during involuntary stepping movements induced by transcutaneous spinal cord electrical stimulation applied in the projection of T ₁₁–T ₁₂ vertebrae and during voluntary stepping movements. It has been found that the transcutaneous spinal cord stimulation inducing stepping movements leads to an increase in breathing frequency and a reduction in tidal volume. These effects may be mediated by some neurogenic factors associated with muscular activity during stepping movements, the activation of abdominal expiratory muscles, and the interaction between the stepping pattern and breathing generators.     

大鼠脊髓诱发电位与脊髓损伤的关系——Ⅲ.脊髓局部损毁后电位的变化及电位来源分析

本文描述了大鼠脊髓L_1节段后柱、后索、侧索和前角的诱发电位及其损伤后的变化,并观察了切断L_4、L_5脊神经背、腹根与横断高位颈髓对电位的影响,以进行行电位来源分析。结果可见,上述四个区域的诱发电位基本由早反应三相波和晚反应组成。分别电解损毁这些部位后,电位波幅均普遍降低,晚期反应较早反应降低明显。后柱或后索受损对电位影响最大。局部损毁后可见L_1及T_(13)水平的硬膜上电位改变明显,尤其晚反应减弱、波峰平坦。反应时值与潜伏时未见明显改变。切断L_4脊神经背、腹根后、电位基本消失。去大脑对电位未见明显影响。结果表明,刺激坐骨神经诱发的脊髓电位起源于低位腰段传入神经和脊髓内多通路的兴奋传导,在一定程度上受腹根逆行活动的影响,与大脑及脊髓下行传导束活动无直接联系。脊髓诱发电位的幅度与波形改变可作为脊髓损伤的判断指标之一。     

Novel method for activation of the locomotor circuitry in human

We examine the possibility for activation of the involuntary locomotion of the lower limbs by spinal electromagnetic stimulation (ES). The subject laid on the left side. The legs are supported in a gravity-neutral position by special mounting that to provide horizontal rotation in the hip, knee and ankle. ES (3 Hz and 1.56 Tesla) at the T11,-T12 vertebrae induced involuntary locomotor-like movements in the legs. The latency from the initiation of ES to the first EMG burst compoused 0.68 +/- 1.0 s and it shortened at increasing of the frequency ES from 3 Hz to 20 Hz. Thus, the spinal ES can unduce the activation of the locomotor movements in human.     

Initiation of Bladder Voiding with Epidural Stimulation in Paralyzed,Step Trained Rats

The inability to control timely bladder emptying is one of the most serious challenges among the several functional deficits that occur after a complete spinal cord injury. Having demonstrated that electrodes placed epidurally on the dorsum of the spinal cord can be used in animals and humans to recover postural and locomotor function after complete paralysis, we hypothesized that a similar approach could be used to recover bladder function after paralysis. Also knowing that posture and locomotion can be initiated immediately with a specific frequency-dependent stimulation pattern and that with repeated stimulation-training sessions these functions can improve even further, we reasoned that the same two strategies could be used to regain bladder function. Recent evidence suggests that rats with severe paralysis can be rehabilitated with a multisystem neuroprosthetic training regime that counteracts the development of neurogenic bladder dysfunction. No data regarding the acute effects of locomotion on bladder function, however, were reported. In this study we show that enabling of locomotor-related spinal neuronal circuits by epidural stimulation also influences neural networks controlling bladder function and can play a vital role in recovering bladder function after complete paralysis. We have identified specific spinal cord stimulation parameters that initiate bladder emptying within seconds of the initiation of epidural stimulation. The clinical implications of these results are substantial in that this strategy could have a major impact in improving the quality of life and longevity of patients while simultaneously dramatically reducing ongoing health maintenance after a spinal cord injury.     

Effects of spinal cord stimulation on spasticity and spasms secondary to myelopathy

16 subjects with severe spasms secondary to traumatic and nontraumatic myelopathy underwent epidural spinal cord stimulation. 4 patients had a complete motor and sensory spinal cord lesion. 6 of the subjects with an incomplete spinal cord lesion were ambulatory. All patients had previously undergone extensive trials with medications and physical therapy. All 14 subjects in whom a satisfactory placement of the electrode could be obtained had a reduction in the severity of the spasms. In 6 patients, the spasms were almost abolished. Extremity, trunkal and abdominal spasms were affected. Clonus in the upper extremities was consistently reduced. Marked improvement in bladder and bowel function was observed in each of 2 subjects. In over 1-year follow-up, 5 subjects show persistence of the results, with less stimulation required to maintain the therapeutic effects. No neurological deterioration occurred following the procedure or after long-term spinal stimulation. 1 patient showed after several months of continuous stimulation increased voluntary motor control present only when spinal cord stimulation was activated. Complications included 1 system infection, 1 electrode migration, 1 wire breakage and skin breakdown at a connector site, development of high impedance in 1 electrode and 1 skin breakdown over the lead.     

Frequency-dependent selection of alternative spinal pathways with common periodic sensory input

Electrical stimulation of the lumbar cord at distinct frequency ranges has been shown to evoke either rhythmical, step-like movements (25–50 Hz) or a sustained extension (5–15 Hz) of the paralysed lower limbs in complete spinal cord injured subjects. Frequency-dependent activation of previously silent spinal pathways was suggested to contribute to the differential responsiveness to distinct neuronal codes and the modifications in the electromyographic recordings during the actual implementation of the evoked motor tasks. In the present study we examine this suggestion by means of a simplified biology-based neuronal network. Involving two basic mechanisms, temporal summation of synaptic input and presynaptic inhibition, the model exhibits several patterns of mono- and/or oligo-synaptic motor output in response to different interstimulus intervals. It thus reproduces fundamental input–output features of the lumbar cord isolated from the brain. The results confirm frequency-dependent spinal pathway selection as a simple mechanism which enables the cord to respond to distinct neuronal codes with different motor behaviours and to control the actual performance of the latter.