Synergistic integration of epidural spinal cord stimulation with robotic therapy and neurorehabilitation to facilitate functional recovery in chronic sensorimotor complete spinal cord injury: A case series.

Objective: To present the rehabilitation considerations in prehabilitation and the rehabilitation phase post spinal cord stimulator implantation; and to evaluate the efficacy of synergistic combination of epidural spinal cord stimulation (SCS) with motor imagery, trunk rehabilitation, robotic and overground gait training in improving mobility in persons with sensorimotor complete spinal cord injury (SCI). Design: A non-controlled before-after clinical trial. Methods: Epidural spinal cord stimulators were implanted into 3 participants with complete thoracic SCI (Thoracic 4, Thoracic 2 and Thoracic 10 respectively). They underwent 1 month of prehabilitation, followed by 7 months of daily rehabilitation post-implantation, consisting of SCS, motor imagery, trunk rehabilitation, robotic therapy and overground gait training. Pre-post assessments include the American Spinal Injury Association Impairment Scale (AIS) examination, Spinal Cord Independence Measure version III (Mobility subscale) (SCIM-III), Walking Index for Spinal Cord Injury II (WISCI-II), Trunk Assessment Scale for Spinal Cord Injury (TASS), Five Times Sit-to-Stand (5×STS) and 2-minute Walk Test (2mWT). Results: Post rehabilitation, there were improvements in WISCI-II, TASS, 5×STS and 2mWT in all 3 participants; and no change in AIS sensory scores. Only participants 2 and 3 exhibited slight improvement in SCIM-III. The WISCI-II of all participants improved, ranging from 3 levels to 9 levels, which was considered a clinically meaningful change. Furthermore, the change in TASS exceeded the minimal clinically important difference (MCID) of 4 points for two participants. The change in 5×STS exceeded the MCID of 2.27 seconds for all participants. These significant improvements translated into the participants' ability to perform sit-to-stand independently and ambulate with a rollator frame under supervision of a carer. Conclusion: This clinical trial demonstrated proof-of-concept and promising findings that support our rehabilitation protocol in improving functional mobility of people with sensorimotor complete SCI, which may be replicated in future studies.*The study protocol was registered with Clinical-trials.gov (NCT05644171; Registered 13 November 2022. https://clinicaltrials.gov/ct2/show/NCT05644171).