The Overlooked Outcome Measure for Spinal Cord Injury: Use of Assistive Devices

Interrater reliability of the Standing and Walking Assessment Tool for spinal cord injury

STUDY DESIGN

Psychometric study.

OBJECTIVES

The Standing and Walking Assessment Tool (SWAT) is a standardized approach to the evaluation of standing and walking capacity following traumatic spinal cord injury (tSCI) in Canada. The SWAT classifies individuals with a tSCI into 12 stages of standing and walking capacity that are paired with well-established outcome measures, such as the Berg Balance Scale and 10-m Walk Test. Prior research has demonstrated the validity and responsiveness of the SWAT stages; however, the reliability remains unknown. The objective of this study was to evaluate the interrater reliability of the SWAT stages.

SETTING

Inpatient units of two Canadian rehabilitation hospitals.

METHODS

Adults with sub-acute tSCI were recruited. SWAT stage was evaluated for each participant by two physical therapists separately. The two therapists aimed to complete the evaluations within one day of each other. To evaluate interrater reliability, the percentage agreement between the SWAT stages rated by the two physical therapists was calculated, along with a linear weighted kappa statistic with a 95% CI.

RESULTS

Forty-five individuals with sub-acute tSCI (36 males, 9 females, mean (SD) age of 54.8 (17.9) years) participated. The percentage agreement in SWAT stages between the two physical therapists was 75.6%. A kappa statistic of 0.93 with a 95% CI, 0.81-1.05 was obtained. In cases where therapists disagreed (18% of participants), therapists differed by 1-2 stages only.

CONCLUSIONS

The SWAT stages have high interrater reliability, providing further support for the use of the SWAT in rehabilitation practice in Canada.

Initial study on an expert system for spine diseases screening using inertial measurement unit

In recent times, widely understood spine diseases have advanced to one of the most urgetn problems where quick diagnosis and treatment are needed. To diagnose its specifics (e.g. to decide whether this is a scoliosis or sagittal imbalance) and assess its extend, various kind of imaging diagnostic methods (such as X-Ray, CT, MRI scan or ST) are used. However, despite their common use, some may be regarded as (to a level) invasive methods and there are cases where there are contraindications to using them. Besides, which is even more of a problem, these are very expensive methods and whilst their use for pure diagnostic purposes is absolutely valid, then due to their cost, they cannot rather be considered as tools which would be equally valid for bad posture screening programs purposes. This paper provides an initial evaluation of the alternative approach to the spine diseases diagnostic/screening using inertial measurement unit and we propose policy-based computing as the core for the inference systems. Although the methodology presented herein is potentially applicable to a variety of spine diseases, in the nearest future we will focus specifically on sagittal imbalance detection.

Exoskeleton gait training with spinal cord neuromodulation

Neuromodulating the locomotor network through spinal cord electrical stimulation (SCES) is effective for restoring function in individuals with gait deficits. However, SCES alone has limited effectiveness without concurrent locomotor function training that enhances activity-dependent plasticity of spinal neuronal networks by sensory feedback. This mini review discusses recent developments in using combined interventions, such as SCES added to exoskeleton gait training (EGT). To develop personalized therapies, it is crucial to assess the state of spinal circuitry through a physiologically relevant approach that identifies individual characteristics of spinal cord function to develop person-specific SCES and EGT. The existing literature suggests that combining SCES and EGT to activate the locomotor network can have a synergistic rehabilitative effect on restoring walking abilities, somatic sensation, and cardiovascular and bladder function in paralyzed individuals.

Feasibility of Customized Pillboxes to Enhance Medication Adherence: A Randomized Controlled Trial

OBJECTIVE

To test the (1) feasibility of an assistive technology based pillbox intervention on medication adherence; (2) feasibility of trial procedures; and (3) preliminary effectiveness of the pillbox intervention on medication adherence.

DESIGN

A single-blinded randomized controlled clinical trial was conducted during 2-4 weeks.

SETTING

Researchers recruited a convenience sample to participate in this university laboratory-based study.

PARTICIPANTS

English-speaking consumers of 2 or more daily medications (N=15) participated in the study. Individuals with cognitive impairment or who did not manage their own medications were excluded.

INTERVENTIONS

Participants were randomized to 1 of 3 pillbox interventions: (1) standard-of-care pillbox; (2) customized off-the-shelf pillbox; or (3) customized 3-dimensional (3D) printed pillbox.

MAIN OUTCOME MEASURES

Outcome measures were divided among the 3 goals of the study. In addition to feasibility metrics, the Adherence to Refills and Medications Scale was used to measure the primary outcome measure, medication adherence. The Quebec User Evaluation of Satisfaction with Assistive Technology was used to measure pillbox satisfaction.

RESULTS

Researchers successfully administered 6 standard-of-care, 5 custom off-the-shelf, and 4 custom 3D printed pillboxes. Compared with the standard-of-care pillboxes, customized 3D printed pillboxes had large (d=1.04) and customized off-the-shelf pillboxes had medium (d=0.67) effects on medication adherence.

CONCLUSIONS

Prescription of customized pillboxes using a manualized and novel assistive technology approach that leverages 3D printing is feasible.

A systematic review identifying outcome measures used in evaluating adults sustaining cervical spine fractures

OBJECTIVE

To assess the outcome measures used in studies investigating cervical spine fractures in adults, with or without associated spinal cord injury, to inform development of a core outcome set.

METHODS

Medline, Embase and Scopus were searched for relevant studies until May 28, 2022, without a historic limit on study date. Study characteristics, population characteristics and outcomes reported were extracted and analyzed.

RESULTS

Our literature search identified 536 studies that met criteria for inclusion, involving 393,266 patients. Most studies were single center (87.3%), retrospective studies (88.9%) and involved a median of 40 patients (range 6-167,278). Treatments assessed included: surgery (55.2%), conservative (6.2%), halo immobilization (4.9%), or a mixture (33.2%). Median study duration was 84 months (range 3-564 months); the timing of clinical and/or radiological follow-up assessment after injury was reported in 56.7%. There was significant heterogeneity in outcomes used, with 79 different reported outcomes measures. Differences in use were identified between smaller/larger, retro-/prospective and single/multicenter cohorts. Over time, the use of radiological outcomes has declined with greater emphasis on patient-reported outcome measures (PROMs). Studies of conservative management were more likely to detail PROMs and mortality, whereas surgical studies reported Frankel/ASIA grade, radiological fusion, complication rates, duration of hospital stay and re-operation rates more frequently. In studies assessing the elderly population (> 65 years), use of PROMs, mortality, hospital stay and discharge destination were more common, whereas fusion was reported less often. Response rates for outcome assessments were lower in studies assessing elderly patients, and studies using PROMs.

CONCLUSIONS

We have classified the various outcome measures used for patients with cervical spine fractures based on the COMET outcome taxonomy. We also described the contexts in which different outcomes are more commonly employed to help guide decision-making when designing future research endeavors.

Use and evaluation of assistive technologies for upper limb function in tetraplegia

CONTEXT

More than half of all spinal cord injuries (SCI) occur at the cervical level leading to loss of upper limb function, restricted activity and reduced independence. Several technologies have been developed to assist with upper limb functions in the SCI population.

OBJECTIVE

There is no clear clinical consensus on the effectiveness of the current assistive technologies for the cervical SCI population, hence this study reviews the literature in the years between 1999 and 2019.

METHODS

A systematic review was performed on the state-of-the-art assistive technology that supports and improves the function of impaired upper limbs in cervical SCI populations. Combinations of terms, covering assistive technology, SCI, and upper limb, were used in the search, which resulted in a total of 1770 articles. Data extractions were performed on the selected studies which involved summarizing details on the assistive technologies, characteristics of study participants, outcome measures, and improved upper limb functions when using the device.

RESULTS

A total of 24 articles were found and grouped into five categories, including neuroprostheses (invasive and non-invasive), orthotic devices, hybrid systems, robots, and arm supports. Only a few selected studies comprehensively reported characteristics of the participants. There was a wide range of outcome measures and all studies reported improvements in upper limb function with the devices.

CONCLUSIONS

This study highlighted that assistive technologies can improve functions of the upper limbs in SCI patients. It was challenging to draw generalizable conclusions because of factors, such as heterogeneity of recruited participants, a wide range of outcome measures, and the different technologies employed.

Integrated Neuroregenerative Techniques for Plasticity of the Injured Spinal Cord

On the slow path to improving the life expectancy and quality of life of patients post spinal cord injury (SCI), recovery remains controversial. The potential role of the regenerative capacity of the nervous system has led to numerous attempts to stimulate the SCI to re-establish the interrupted sensorimotor loop and to understand its potential in the recovery process. Numerous resources are now available, from pharmacological to biomolecular approaches and from neuromodulation to sensorimotor rehabilitation interventions based on the use of various neural interfaces, exoskeletons, and virtual reality applications. The integration of existing resources seems to be a promising field of research, especially from the perspective of improving living conditions in the short to medium term. Goals such as reducing chronic forms of neuropathic pain, regaining control over certain physiological activities, and enhancing residual abilities are often more urgent than complete functional recovery. In this perspective article, we provide an overview of the latest interventions for the treatment of SCI through broad phases of injury rehabilitation. The underlying intention of this work is to introduce a spinal cord neuroplasticity-based multimodal approach to promote functional recovery and improve quality of life after SCI. Nonetheless, when used separately, biomolecular therapeutic approaches have been shown to have modest outcomes.

The role of arousal and motivation in emotional conflict resolution: Implications for spinal cord injury

Under many conditions, emotional information is processed with priority and it may lead to cognitive conflict when it competes with task-relevant information. Accordingly, being able to ignore emotional information relies on cognitive control. The present perspective offers an integrative account of the mechanism that may underlie emotional conflict resolution in tasks involving response activation. We point to the contribution of emotional arousal and primed approach or avoidance motivation in accounting for emotional conflict resolution. We discuss the role of arousal in individuals with impairments in visceral pathways to the brain due to spinal cord lesions, as it may offer important insights into the “typical” mechanisms of emotional conflict control. We argue that a better understanding of emotional conflict control could be critical for adaptive and flexible behavior and has potential implications for the selection of appropriate therapeutic interventions.

Functional recovery priorities and community rehabilitation service preferences of spinal cord injury individuals and caregivers of Chinese ethnicity and cultural background

Introduction

Spinal cord injury (SCI) causes significant and permanent disability affecting motor, sensory and autonomic functions. We conducted a survey on the priorities of functional recovery and preferences for community rehabilitation services in a cohort of Chinese individuals with SCI as well as the primary caregivers. The study also investigated their views on advanced technology and research.

Methods

An online platform with a self-administered questionnaire was used to collect the opinions of clients that received services from an SCI follow-up clinic, a self-help association, or a non-government organization from 1 September−31 December 2021.

Results

Eighty-seven subjects (74 individuals with SCI−48 tetraplegic, 26 paraplegic, and 13 caregivers) responded to the survey. Recovery of arm/hand function was given the highest priority among tetraplegics, followed by upper trunk/body strength and balance, and bladder/bowel function. Sexual function had a significant lower ranking than all priority areas except normal sensation (p < 0.05). Paraplegics viewed bladder/bowel function as the most important area of functional recovery, followed by walking movement, upper trunk/body strength and balance, elimination of chronic pain, and regaining normal sensation. There was no statistically significant difference among the top priority areas (p > 0.05). In contrast to previous studies done in Western populations, the study revealed that sexual function was ranked as the lowest by all 3 groups of respondents (tetraplegics, paraplegics, and caregivers). The majority of participants thought community rehabilitation services were inadequate. Most of the respondents were interested to try advanced technology which would facilitate their daily life and rehabilitation. About half of the individuals with SCI thought advance in technology and research could bring significant improvement in their quality of life in the coming 10 years.

Conclusion

This survey is the first study specifically looking into the recovery and rehabilitation priorities of a Chinese population of individuals with SCI. This is also the first study to investigate the priorities of the primary caregivers of SCI individuals. The findings are useful as a reference for planning of future research and provision of rehabilitation services for the SCI community locally and in other parts of China.

Validity and responsiveness of the Standing and Walking Assessment Tool for sub-acute traumatic spinal cord injury

STUDY DESIGN

This is a retrospective longitudinal study.

OBJECTIVE

The Standing and Walking Assessment Tool (SWAT) combines stages of standing and walking recovery (SWAT stages) with established measures (Berg Balance Scale (BBS), 10-m walk test (10MWT), 6-min walk test (6MWT), and modified Timed Up-and-Go (mTUG)). We evaluated the SWAT's validity (known-groups and convergent) and responsiveness among inpatients with sub-acute, traumatic spinal cord injury (SCI).

SETTING

Ten Canadian rehabilitation hospitals.

METHODS

Upon admission, SWAT stage and core measures (BBS, 10MWT, 6MWT, and mTUG), International Standards for Neurological Classification of SCI sensory and motor scores, and Spinal Cord Independence Measure III (SCIM) were collected from 618 adults with SCI. Known-groups validity was evaluated by comparing SWAT stage distributions across American Spinal Injury Association Impairment Scale (AIS) classification. Convergent validity was evaluated by correlating SWAT stages with scores on other measures using Spearman's rho. The SWAT (stage and core measures) was re-administered at discharge. To evaluate responsiveness, SWAT stages at admission and discharge were compared. The standardized response mean (SRM) was used to evaluate the responsiveness of core SWAT measures.

RESULTS

The SWAT stage distribution of participants with AIS D injuries differed from those of participants with AIS A-C injuries (p ≤ 0.002). SWAT stages correlated strongly with BBS and motor scores (ρ = 0.778-0.836), and moderately with SCIM, mTUG, 10MWT, 6MWT, and sensory scores (ρ = 0.409-0.692). Discharge SWAT stage was greater than the admission stage (p < 0.0001). The BBS was the most responsive core SWAT measure (SRM = 1.26).

CONCLUSIONS

The SWAT is a valid and responsive approach to the measurement of standing and walking ability during sub-acute SCI.

Future Treatment of Neuropathic Pain in Spinal Cord Injury: The Challenges of Nanomedicine, Supplements or Opportunities?

Neuropathic pain (NP) is a common chronic condition that severely affects patients with spinal cord injuries (SCI). It impairs the overall quality of life and is considered difficult to treat. Currently, clinical management of NP is often limited to drug therapy, primarily with opioid analgesics that have limited therapeutic efficacy. The persistence and intractability of NP following SCI and the potential health risks associated with opioids necessitate improved treatment approaches. Nanomedicine has gained increasing attention in recent years for its potential to improve therapeutic efficacy while minimizing toxicity by providing sensitive and targeted treatments that overcome the limitations of conventional pain medications. The current perspective begins with a brief discussion of the pathophysiological mechanisms underlying NP and the current pain treatment for SCI. We discuss the most frequently used nanomaterials in pain diagnosis and treatment as well as recent and ongoing efforts to effectively treat pain by proactively mediating pain signals following SCI. Although nanomedicine is a rapidly growing field, its application to NP in SCI is still limited. Therefore, additional work is required to improve the current treatment of NP following SCI.

Exoskeletons for Mobility after Spinal Cord Injury: A Personalized Embodied Approach

Endowed with inherent flexibility, wearable robotic technologies are powerful devices that are known to extend bodily functionality to assist people with spinal cord injuries (SCIs). However, rather than considering the specific psychological and other physiological needs of their users, these devices are specifically designed to compensate for motor impairment. This could partially explain why they still cannot be adopted as an everyday solution, as only a small number of patients use lower-limb exoskeletons. It remains uncertain how these devices can be appropriately embedded in mental representations of the body. From this perspective, we aimed to highlight the homeostatic role of autonomic and interoceptive signals and their possible integration in a personalized experience of exoskeleton overground walking. To ensure personalized user-centered robotic technologies, optimal robotic devices should be designed and adjusted according to the patient's condition. We discuss how embodied approaches could emerge as a means of overcoming the hesitancy toward wearable robots.

Rethinking the Body in the Brain after Spinal Cord Injury

Spinal cord injuries (SCI) are disruptive neurological events that severly affect the body leading to the interruption of sensorimotor and autonomic pathways. Recent research highlighted SCI-related alterations extend beyond than the expected network, involving most of the central nervous system and goes far beyond primary sensorimotor cortices. The present perspective offers an alternative, useful way to interpret conflicting findings by focusing on the deafferented and deefferented body as the central object of interest. After an introduction to the main processes involved in reorganization according to SCI, we will focus separately on the body regions of the head, upper limbs, and lower limbs in complete, incomplete, and deafferent SCI participants. On one hand, the imprinting of the body’s spatial organization is entrenched in the brain such that its representation likely lasts for the entire lifetime of patients, independent of the severity of the SCI. However, neural activity is extremely adaptable, even over short time scales, and is modulated by changing conditions or different compensative strategies. Therefore, a better understanding of both aspects is an invaluable clinical resource for rehabilitation and the successful use of modern robotic technologies.

Walking improvement in chronic incomplete spinal cord injury with exoskeleton robotic training (WISE): a randomized controlled trial

STUDY DESIGN

Clinical trial.

OBJECTIVE

To demonstrate that a 12-week exoskeleton-based robotic gait training regimen can lead to a clinically meaningful improvement in independent gait speed, in community-dwelling participants with chronic incomplete spinal cord injury (iSCI).

SETTING

Outpatient rehabilitation or research institute.

METHODS

Multi-site (United States), randomized, controlled trial, comparing exoskeleton gait training (12 weeks, 36 sessions) with standard gait training or no gait training (2:2:1 randomization) in chronic iSCI (>1 year post injury, AIS-C, and D), with residual stepping ability. The primary outcome measure was change in robot-independent gait speed (10-meter walk test, 10MWT) post 12-week intervention. Secondary outcomes included: Timed-Up-and-Go (TUG), 6-min walk test (6MWT), Walking Index for Spinal Cord Injury (WISCI-II) (assistance and devices), and treating therapist NASA-Task Load Index.

RESULTS

Twenty-five participants completed the assessments and training as assigned (9 Ekso, 10 Active Control, 6 Passive Control). Mean change in gait speed at the primary endpoint was not statistically significant. The proportion of participants with improvement in clinical ambulation category from home to community speed post-intervention was greatest in the Ekso group (>1/2 Ekso, 1/3 Active Control, 0 Passive Control, p < 0.05). Improvements in secondary outcome measures were not significant.

CONCLUSIONS

Twelve weeks of exoskeleton robotic training in chronic SCI participants with independent stepping ability at baseline can improve clinical ambulatory status. Improvements in raw gait speed were not statistically significant at the group level, which may guide future trials for participant inclusion criteria. While generally safe and tolerable, larger gains in ambulation might be associated with higher risk for non-serious adverse events.

A Therapeutic Matrix: Virtual Reality as a Clinical Tool for Spinal Cord Injury-Induced Neuropathic Pain

Neuropathic pain (NP) is a chronic, debilitating, and resistant form of pain. The onset rate of NP following spinal cord injuries (SCI) is high and may reduce the quality of life more than the sensorimotor loss itself. The long-term ineffectiveness of current treatments in managing symptoms and counteracting maladaptive plasticity highlights the need to find alternative therapeutic approaches. Virtual reality (VR) is possibly the best way to administer the specific illusory or reality-like experience and promote behavioral responses that may be effective in mitigating the effects of long-established NP. This approach aims to promote a more systematic adoption of VR-related techniques in pain research and management procedures, highlighting the encouraging preliminary results in SCI. We suggest that the multisensory modulation of the sense of agency and ownership by residual body signals may produce positive responses in cases of brain-body disconnection. First, we focus on the transversal role embodiment and how multisensory and environmental or artificial stimuli modulate illusory sensations of bodily presence and ownership. Then, we present a brief overview of the use of VR in healthcare and pain management. Finally, we discus research experiences which used VR in patients with SCI to treating NP, including the most recent combinations of VR with further stimulation techniques.

Development and Validation of Crosswalks Between FIM® and SCIM III for Voluntary Musculoskeletal Movement Functions

Background. In spinal cord injury, there are multiple databases containing information on functional recovery, but data cannot be pooled or compared due to differences in how function is measured. A crosswalk is needed to link or convert scores between instruments. Objectives. To create a crosswalk between the voluntary musculoskeletal movement items in the Functional Independence Measure (FIM®) and the Spinal Cord Independence Measure III (SCIM III) for spinal cord injury. Methods. Retrospective datasets with FIM® and SCIM III on the same people were used to develop (Swiss dataset, n = 662) and validate (US, n = 119, and Canadian datasets, n = 133) the crosswalks. Three different crosswalk methods (expert panel, equipercentile, and Rasch analysis) were employed. We used the correlation between observed scores on FIM® and SCIM III to crosswalked scores as the primary criterion to assess the strength of the crosswalk. Secondary criteria such as score distributions, Cohen's effect size, point differences, and subgroup invariance were also evaluated. Results. All three methods resulted in strong correlation coefficients, exceeding the primary criterion value of r = .866 (.897-.972). Assessment of secondary criteria suggests the equipercentile and Rasch methods produced the strongest crosswalks. Conclusions. The Rasch FIM®/SCIM III crosswalk is recommended because it is based on co-calibration of linearized measures, allowing for more sophisticated parametric analyses. The crosswalk will allow comparisons of voluntary musculoskeletal functional recovery across international databases using different functional measures, as well as different systems of care and rehabilitation approaches.

Implementing Patient-Reported Outcome Measures in Inpatient Rehabilitation: Challenges and Solutions

A project with the goal of implementing electronic health record (EHR) - based patient-reported outcome measures (PROMs) into a large inpatient spinal cord injury (SCI) rehabilitation program took twice as long as expected. This report details the lessons learned from the barriers, successes, and unexpected issues that arose during this prolonged, but now successful project. The goals of this implementation project were to (1) identify barriers and supports to the use of PROMs; (2) develop an implementation strategy to incorporate the use of PROMs into inpatient rehabilitation; and (3) implement the strategy and evaluate its effects on team communication. In brief, we conducted an initial pilot phase outside of the EHR and used our findings to guide procedural and EHR incorporation during a demonstration phase. We encountered multiple barriers. Procedural issues were significant: even though grant funding covered the cost of writing the code for integration of the PROMs into the EHR, our institution's competing priorities slowed progress. Institutional inertia was reflected in the reluctance of some clinical staff members to assume new duties that would take away from direct patient care responsibilities. Therefore, we needed to obtain additional staffing. Detailed planning upfront, guided by changes when necessary, cooperation and interaction with our institution's Information Systems department, and identification of key players and implementation champions proved essential to our success. We now have an up-and-running system and are sharing our experience, observations, and recommendations to assist other healthcare organizations incorporate PROMs into their EHRs.

Go Virtual to Get Real: Virtual Reality as a Resource for Spinal Cord Treatment

Increasingly, refined virtual reality (VR) techniques allow for the simultaneous and coherent stimulation of multiple sensory and motor domains. In some clinical interventions, such as those related to spinal cord injuries (SCIs), the impact of VR on people's multisensory perception, movements, attitudes, and even modulations of socio-cognitive aspects of their behavior may influence every phase of their rehabilitation treatment, from the acute to chronic stages. This work describes the potential advantages of using first-person-perspective VR to treat SCIs and its implications for manipulating sensory-motor feedback to alter body signals. By situating a patient with SCI in a virtual environment, sensorial perceptions and motor intention can be enriched into a more coherent bodily experience that also promotes processes of neural regeneration and plasticity. In addition to the great potential of research, the most significant areas of interest concern is managing neuropathic pain, motor rehabilitation, and psychological well-being.

Preliminary steps of the development of a Minimum Uniform Dataset applicable to the international wheelchair sector

Assistive products outcomes are needed globally to inform policy, practice, and drive investment. The International Society of Wheelchair Professionals developed a Minimum Uniform Dataset (MUD) for wheelchair services worldwide with the intent to gather data that is comparable globally. The MUD was developed with the participation of members from around the globe and its feasibility piloted at 3 sites. Three versions of the MUD are now available—a short form with 29 data points (available in English, Spanish, and French) and a standard version with 38 data points in English. Future work is to validate and complete the translation cycles followed by promoting the use of the MUD globally so that the data can be leveraged to inform policy, practice and direct investments.

Exoskeleton Walk Training in Paralyzed Individuals Benefits From Transcutaneous Lumbar Cord Tonic Electrical Stimulation

In recent years, advanced technologies featuring wearable powered exoskeletons and neuromodulation of lumbosacral spinal networks have been developed to facilitate stepping and promote motor recovery in humans with paralysis. Here we studied a combined effect of spinal cord electrical stimulation (SCES) and exoskeleton walk training (EWT) during an intensive 2-week rehabilitative protocol in spinal cord injury individuals (n = 19, American Spinal Injury Association Impairment Scale (AIS) A-11, B-5, C-3). The purpose of this study was to evaluate the compatibility of methods and to explore the main effects of combined SCES and EWT. All participants had a chronic state of paralysis (1–11 years after trauma). In addition, in the control group (n = 16, AIS A-7, B-5, C-4), we performed EWT without SCES. For EWT, we used a powered exoskeleton (ExoAtlet), while stability was assisted by crutches, with automatic arrest of stepping if excessive torques were detected. SCES was applied to the level of the mid-lumbar cord over the Th12 vertebra at 1 or 3 pulses/s (4 individuals with severe spasticity were also stimulated in an anti-spastic mode 67 pulses/s). The vertical component of the ground reaction force was recorded using the F-Scan system at the onset and after training with SCES. EWT with SCES significantly increased the foot loading forces, could decrease their asymmetry and 8 out of 19 subjects improved their Hauser Ambulation Index. The anti-spastic mode of stimulation also allowed individuals with severe spasticity to walk with the aid of the exoskeleton. Participants reported facilitation when walking with SCES, paresthesia in leg muscles and new non-differential sensation of passive motion in leg joints. Neurological examination showed an increase of tactile (7) and/or pain (7) sensation and an increase of the AIS motor scale in 9 individuals, including both incomplete and complete paralysis. Improvements in the neurological scores were, however, limited in the control group (EWT without SCES). The results suggest that SCES may facilitate training and walking in the exoskeleton by activating the locomotor networks and augmenting compensative sensitivity.

Acquisition of Ownership Illusion with Self-Disownership in Neurological Patients

The multisensory regions in frontoparietal cortices play a crucial role in the sense of body and self. Disrupting this sense may lead to a feeling of disembodiment, or more generally, a sense of disownership. Experimentally, this altered consciousness disappears during illusory own-body perceptions, increasing the intensity of perceived ownership for an external virtual limb. In many clinical conditions, particularly in individuals with a discontinuous or absent sense of bodily awareness, the brain may effortlessly create a convincing feeling of body ownership over a surrogate body or body part. The immediate visual input dominates the current bodily state and induces rapid plastic adaptation that reconfigures the dynamics of bodily representation, allowing the brain to acquire an alternative sense of body and self. Investigating strategies to deconstruct the lack of a normal sense of bodily ownership, especially after a neurological injury, may aid the selection of appropriate clinical treatment.

Disconnected Body Representation: Neuroplasticity Following Spinal Cord Injury

Neuroplastic changes in somatotopic organization within the motor and somatosensory systems have long been observed. The interruption of afferent and efferent brain–body pathways promotes extensive cortical reorganization. Changes are majorly related to the typical homuncular organization of sensorimotor areas and specific “somatotopic interferences”. Recent findings revealed a relevant peripheral contribution to the plasticity of body representation in addition to the role of sensorimotor cortices. Here, we review the ways in which structures and brain mechanisms react to missing or critically altered sensory and motor peripheral signals. We suggest that these plastic events are: (i) variably affected across multiple timescales, (ii) age-dependent, (iii) strongly related to altered perceptual sensations during and after remapping of the deafferented peripheral area, and (iv) may contribute to the appearance of secondary pathological conditions, such as allodynia, hyperalgesia, and neuropathic pain. Understanding the considerable complexity of plastic reorganization processes will be a fundamental step in the formulation of theoretical and clinical models useful for maximizing rehabilitation programs and resulting recovery.