Abstract
IntroductionPaired associative stimulation (PAS) is a combination of transcranial magnetic stimulation (TMS) and peripheral nerve stimulation (PNS) and induces plastic changes in the human corticospinal tract. We have previously shown that PAS consisting of TMS pulses given at 100% of stimulator output and high-frequency PNS is beneficial for motor rehabilitation of patients with a chronic incomplete spinal cord injury (SCI). The therapeutic possibilities of this PAS variant for walking rehabilitation of paraplegic patients are unexplored.Case presentationA 47-year old man with traumatic incomplete paraplegia (AIS D, neurological level T7) received PAS to his left leg for 3 months at 12 months post injury (PAS1) and for an additional 3 months at 24 months post injury (PAS2). The right leg had normal AIS scores and was not stimulated. Before PAS, the patient was nonambulatory, could not stand without weight support, and was consequently not eligible for conventional walking rehabilitation. After PAS1, the patient could stand for 1.5 min and take 13 steps (24 steps in follow up) on parallel bars without weight support and was enrolled into conventional walking rehabilitation. He achieved independent walking ability with a rollator. During PAS2, walking distance increased 2.4 times faster than during the preceding year. The left leg AIS score and spinal cord independence measure mobility subscore increased. No adverse effects were detected.DiscussionThis is the first report of PAS with a high-frequency peripheral component that enabled and promoted walking rehabilitation. Together with previous reports on this technique, this result encourages further research into its therapeutic potential and mechanism.
Highlights
Paired associative stimulation (PAS) is a combination of transcranial magnetic stimulation (TMS) and peripheral nerve stimulation (PNS) and induces plastic changes in the human corticospinal tract
Since conventional PAS protocols strongly depend on the exact determination of the interval between TMS and PNS and on numerous other conditions [4], we developed a modified version of PAS
The resting motor threshold (RMT) in all muscles was over 100% of the maximum stimulator output (MSO) of the TMS device and all M1 mapping was performed with a weak motor preactivation
Summary
This is the first case report demonstrating that PAS with high-frequency PNS may contribute to regaining of overground walking after an incomplete paraplegia. We stimulated for the first time all four major nerves of the lower limb in a paraplegic patient in two periods of 12 weeks at two difference phases of rehabilitation; first. As in our previous patient reports, the patient did not have a sports background and is representative of the usual population of SCI patients Since this is a case report, the exact role of PAS vs natural recovery and the impact of conventional rehabilitation naturally remains open. Together with our previous results [7, 11,12,13,14], this suggests that PAS might be useful for patients who require additional muscle strength needed for walking rehabilitation. Together with our previous studies [7, 11,12,13,14], this study justifies larger PAS trials for patients with different types and stages of SCI
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