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Electromyography (EMG)-triggered transcutaneous spinal cord and hip stimulation for gait rehabilitation in persons with chronic stroke: a randomized, controlled trial
Journal of NeuroEngineering and Rehabilitation 22, Article number: 154 (2025)
Abstract
Background
Transcutaneous spinal stimulation has been applied to gait rehabilitation for persons with neurological diseases. The authors developed electromyography-triggered transcutaneous spinal cord and hip stimulation for gait rehabilitation and called this system FAST walk. This study aimed to assess the effect of FAST walk in a randomized, controlled trial.
Methods
All participants were randomly allocated to three groups: FAST walk combined with treadmill gait training (FAST walk); spinal stimulation combined with treadmill gait training (spinal stim); and treadmill gait training (treadmill). Participants performed two sets of 15-min treadmill gait training with 5-min intervals in the FAST walk, spinal stim, and treadmill groups. Gait training was performed twice weekly for a total of 10 sessions. The primary outcome was 10-m walking time. The secondary outcomes were the time symmetry index (TSI) with gait analysis and spinal reciprocal inhibition on the conditioned-test H reflex study.
Results
Twenty persons with chronic stroke participated in this study, and 17 persons completed this study. For the primary outcome, there was no significant interaction between time and intervention in 10-m walking time on two-way analysis of covariance (ANCOVA) (P = 0.382, η2 = 0.064). For the FAST walk group, 10-m walking time improved significantly at post and post-4w (P = 0.024 and 0.022, respectively). In the other groups, no significant improvements in 10-m walking time were seen at post and post-4w compared with before. There was also no significant between-group difference in the 10-m walking time.
Conclusions
The newly developed electromyography-triggered transcutaneous spinal cord and hip stimulation, FAST walk, is safe and may improve the gait speed of persons with chronic stroke. We did not, however, find a significant between-group difference among the FAST walk, spinal stim, and treadmill gait groups.
Trial registration: Japan Registry of Clinical Trial (JRCT registration ID: jRCTs032180289).
Introduction
Most persons with stroke suffer a gait disturbance. The goal of rehabilitation medicine is to help persons acquire independence of locomotion, and improvement of gait function is one of the primary goals of stroke rehabilitation. More than 80% of persons with stroke, however, show gait impairment [1]. A cohort study reported that 22% of persons with stroke did not regain any walking function [2]. Eighty percent of persons with stroke regained gait independence, but gait speed was limited. A previous study showed that gait speed determined the ambulation category of full community, limited community, and home ambulators [3], and gait impairment determined the participation of persons with stroke.
Conventional therapist-assisted gait training, muscle strengthening, partial weight-bearing treadmill gait training, robot-assisted gait training, and functional electrical stimulation have been applied in gait rehabilitation [4, 5].
Recently, spinal cord stimulation has been applied in gait rehabilitation for spinal cord injury, Parkinson’s disease, and stroke [6,7,8,9,10]. Supra-threshold lumbosacral spinal cord stimulation generated smooth, coordinated, flexion–extension movements at the hip, knee, and ankle [11]. This finding suggested that there existed a spinal locomotor circuit in the spinal cord. Minassian et al. [12] showed that subthreshold transcutaneous spinal electrical stimulation at Th11-12 evoked posterior root muscle reflexes in bilateral quadriceps, hamstrings, tibialis anterior, and triceps surae muscles. This finding suggested that subthreshold spinal electrical stimulation might activate a large diameter of the dorsal root afferent nerves. Spinal electrical stimulation of the lumbosacral spinal cord modulates the activity of motor neurons by activating a large diameter of the dorsal root afferent nerve [13]. Continuous spinal stimulation induced rhythmic lower extremity EMG activity, and sub-threshold spinal stimulation increased muscle activities of the lower extremities in rats with spinal cord injuries [14]. It was supposed that there existed spinal locomotor circuit and this spinal locomotor circuitry consists of spinal reflexes (e.g., crossed extensor reflex, flexor reflex) and contributes to the stereotyped locomotive movement [15, 16].
Hip extension at the late stance phase may produce an initial swing of the paralyzed lower extremity [17]. The crossed extensor reflex induces the reciprocating hip movement [18]. Hip extension is a strong trigger of the crossed extensor reflex. Hip sensory afferents induced by hip movements regulate locomotion [19]. In patients with stroke, late stance assisted-hip extension decreased the primary sensorimotor cortex activity and promoted the rhythmic coordinated gait pattern [20]. It was supposed that assisted-hip extension enhances the activity of the spinal locomotor circuit and the effect of spinal stimulation in patients with stroke.
It is hypothesized that subthreshold spinal stimulation combined with hip extensor stimulation activates spinal locomotor circuitry in the spinal cord, which contributes to locomotion. We, therefore, developed a new electromyography (EMG)-triggered transcutaneous spinal and hip stimulation system called FAST walk.
This study aimed to assess the effect of FAST walk combined with treadmill training in persons with chronic stroke in a randomized, controlled trial (RCT). We hypothesized that FAST walk combined with treadmill training improves gait function compared to the spinal stimulation combined with treadmill training, and treadmill training.
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