Case Report: Efficacy of transcutaneous spinal cord stimulation combined with overground robotic-assisted gait training in chronic incomplete spinal cord injury

Abstract

Background – Spinal cord injury (SCI) causes significant motor, sensory, and autonomic dysfunction, with gait recovery being a primary rehabilitation goal. Transcutaneous spinal cord stimulation (tSCS) combined with robotic-assisted gait training (RAGT) represents a promising synergistic approach to enhance motor recovery, though evidence for overground exoskeletal training with tSCS remains limited. Case presentation – We report a 40-year-old male with chronic incomplete traumatic SCI (T5, ASIA D) who underwent a two-phase intervention: Phase I consisted of 16 sessions of overground RAGT using the EksoGT exoskeleton, followed by Phase II comprising 16 sessions of RAGT combined with tSCS using the ARC-EX system. Comprehensive assessments included ISNCSCI neurological examination, 10-meter walk test (10MWT), spatiotemporal gait analysis, surface electromyography (EMG), and central motor conduction time (CMCT). Results – The participant demonstrated substantial improvements in gait speed from 0.26 m/s at baseline to 0.41 m/s at four-week follow-up (Δ = +0.15 m/s), exceeding the minimal clinically important difference of 0.13 m/s. Lower Extremity Motor Score improved from 35/50 to 42/50, with notable distal lower limb gains. Cadence increased from 31.53 to 39.74 steps/min (right) and 33.29 to 38.67 steps/min (left), while stride length improved from 0.91 m to 1.17 m (right) and 0.95 m to 1.17 m (left). EksoGT MinAssist values decreased from an average of 61 (Phase I) to 50 (Phase II), indicating greater active participant engagement with tSCS. EMG recordings demonstrated enhanced neuromuscular activation following tSCS, with more organized muscle recruitment patterns. CMCT decreased from 21.9 ms to 19.7 ms on the right side, suggesting improved corticospinal tract conduction. EQ-VAS improved from 80 to 90. No adverse events were reported. Conclusion – This is the first reported case integrating tSCS with overground exoskeletal training in SCI rehabilitation. The combination of tSCS and RAGT appears safe and may provide synergistic benefits for motor recovery, particularly when conventional therapy reaches a plateau. These findings support further investigation through larger controlled studies to validate optimal stimulation protocols and generalizability.