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Based on a comment regarding one of my last blog posts about what works with intervertebral disc disease (IVDD) recovery in dogs, I went down the rabbit hole to look into what has been researched and validated in human spinal cord injury treatment and recovery of function.  Here’s what I found.

Rehabilitation for spinal cord injury (SCI) patients focuses on promoting neuroplasticity, restoring motor and sensory functions, and improving overall quality of life through evidence-based techniques. While complete recovery is rare, several approaches have been validated in clinical trials, meta-analyses, systematic reviews, and animal models to enhance functional return and neurologic status. These include neuromodulation, exercise-based therapies, electrical stimulation, and emerging multimodal strategies. Below is a summary of key validated techniques, grouped by category, with supporting evidence and outcomes.

Neuromodulation and Electrical Stimulation Techniques

•  Epidural Spinal Cord Stimulation (eSCS or EES): Involves implanted electrodes delivering electrical pulses to the spinal cord, often combined with rehabilitation training. It activates residual neural pathways, promotes plasticity, and restores voluntary movement. Validated in human trials for chronic SCI, showing improved gait, standing, and autonomic functions (e.g., bladder control) in patients with incomplete injuries. Outcomes include partial motor recovery and reduced pain, with efficacy varying by stimulation parameters and injury level.

•  Functional Electrical Stimulation (FES): (i.e. neuromuscular electrical stimulation) Applies electrical pulses to nerves or muscles to induce contractions, bypassing damaged pathways. Often used with cycling or gait training. Meta-analyses and reviews confirm enhancements in muscle strength, endurance, joint mobility, and neural plasticity in both upper and lower limbs. It improves daily activities like walking and grasping, with better results when integrated with physical therapy.

•  Peripheral Nerve Stimulation (PNS): (i.e. TENS or Interferential current)Targets peripheral nerves to interrupt pain signals and promote plasticity. Retrospective studies show significant reductions in spasms, pain, and motor deficits in SCI patients, accelerating nerve regeneration. Outcomes include enhanced quality of life and functional status, though long-term data is limited.

•  Transcranial Magnetic Stimulation (TMS or rTMS): Non-invasive stimulation of the brain to enhance corticospinal excitability. Clinical studies demonstrate improvements in hindlimb strength, gait, and motor control in incomplete SCI. It supports neuroplasticity and is effective as an adjunct to rehab.

Exercise and Physical Therapy Techniques

•  Aerobic and Strength Training: Guidelines recommend starting with 20 minutes of moderate-to-vigorous aerobic exercise (e.g., arm cycling, hybrid arm-leg cycling) twice weekly, progressing to 30 minutes three times weekly, plus strength training for major muscle groups twice weekly. Intensity is gauged by perceived exertion (RPE 4–7/10). Systematic reviews and physiological studies show improvements in cardiorespiratory fitness, muscle mass, power output, and physical function (e.g., wheeling, transfers). It reduces neuropathic pain via anti-inflammatory effects, mitigates sarcopenic obesity, and enhances neurologic status by preserving muscle fibers and promoting mitochondrial function.

•  Locomotor Training (e.g., Bodyweight-Supported Treadmill Training): Involves supported walking on a treadmill to activate spinal circuits and induce plasticity. Animal and human studies, including meta-analyses, validate its role in upregulating growth factors (e.g., BDNF) and remodeling neural pathways, leading to better gait, balance, and motor scores. Optimal when started 1–2 weeks post-injury, with superior outcomes in combination therapies.

•  Virtual Reality-Based Therapy (VRBT): Uses immersive VR for balance and functional exercises, compared to conventional therapy. A systematic review of trials shows moderate evidence for greater improvements in balance (e.g., Berg Balance Scale) and functional status (e.g., Functional Independence Measure) in SCI patients. It enhances engagement and neuroplasticity, though more large-scale RCTs are needed.

Other Validated Approaches

•  Acupuncture and Electro-Acupuncture: Needle-based stimulation at specific points to reduce inflammation and promote regeneration. Acupuncture may have a beneficial effect on neurological recovery  motor function, and functional recovery. However, study quality was poor, with a large potential for confirmation bias.  Electro-Acupuncture improves activities of daily living and motor function in patients with SCI, with a moderate level of evidence.

•  Photobiomodulation (PBM) or Low-Level Laser Therapy: Non-invasive light therapy to regulate astrocytes and mitochondrial function. PBM was effective in improving post-SCI movement in the first 14 days and this improvement became even greater thereafter.  It supports neuroregeneration and is safe as an adjunct.

•  Combination Therapies (CIRT): Integrating rehab (e.g., treadmill training) with strategies like neuromodulation, stem cells, or pharmacology. A meta-analysis of 87 animal studies shows superior motor recovery (e.g., 1.40 weighted mean difference in locomotor scores) compared to single modalities, promoting synaptic reorganization without worsening spasticity. Human trials confirm enhanced functional independence and quality of life.

Conclusion

What is of interest to note is that within the results found, passive therapies such as massage and ROM were not included.  Modalities and active therapies however, could be validated.  Why then are ROM and massage included in some clinical canine IVDD studies?  Our time as rehabilitation therapists is better spent on using or performing therapies with a proven track record.  Delving into human research helps to direct our efforts, and presumably results.

Reference:

1. Arroyo-Fernández, R., Menchero-Sánchez, R., Pozuelo-Carrascosa, D. P., et al. (2024). Effectiveness of body weight-supported gait training on gait and balance for motor-incomplete spinal cord injuries: A systematic review with meta-analysis. Journal of Clinical Medicine, 13(4), Article 1105.
2. Gill, M. L., Grahn, P. J., Calvert, J. S., et al.  (2018). Neuromodulation of lumbosacral spinal networks enables independent stepping after complete paraplegia. Nature Medicine, 24(11), 1677–1682.
3. James, N. D., McMahon, S. B., Field-Fote, E. C., & Bradbury, E. J. (2018). Neuromodulation in the restoration of function after spinal cord injury. The Lancet Neurology, 17(10), 905–917. 
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