Recovery of Over-Ground Walking after Chronic Motor Complete Spinal Cord Injury
Open accessAbstract
Summ a r yPersons with motor complete spinal cord injury, signifying no voluntary movement or sphincter function below the level of injury but including retention of some sensation, do not recover independent walking.We tested intense locomotor treadmill training with weight support and simultaneous spinal cord epidural stimulation in four patients 2.5 to 3.3 years after traumatic spinal injury and after failure to improve with locomotor training alone.Two patients, one with damage to the mid-cervical region and one with damage to the high-thoracic region, achieved over-ground walking (not on a treadmill) after 278 sessions of epidural stimulation and gait training over a period of 85 weeks and 81 sessions over a period of 15 weeks, respectively, and all four achieved independent standing and trunk stability.One patient had a hip fracture during training.(Funded by the Leona M. and Harry B. Helmsley Charitable Trust and others; ClinicalTrials.govnumber, NCT02339233.)T here are estimated to be 1,275,000 persons with paralysis from spinal cord injury in the United States. 1 These patients indicate in surveys that walking and standing are highly desirable goals. 2 We have previously shown that epidural stimulation of the spinal cord and simultaneous intense rehabilitation may allow the restoration of some volitional movement below the level of spinal injury 3,4 and may result in the ability to stand independently.5,6 We report here recovery of independent walking over ground, not on a treadmill, in two of four patients with motor complete paralysis, with the use of a program that combines customized epidural spinal cord stimulation and intense training in standing and stepping.The study was approved by the institutional review board at the University of Louisville and was conducted in accordance with the Declaration of Helsinki.All the patients provided written informed consent.All the authors vouch for the completeness and accuracy of the data and the reporting of adverse events and for the adherence of the study to the protocol, available with the full text of this article at NEJM.org.Medtronic provided the epidural electrode arrays, neurostimulators, programming devices, and recharging units to the Kentucky Spinal Cord Injury Research Center at the University of Louisville.There was no other industry involvement, and no funds were given by Medtronic to the institution, investigators, or research participants.The delay between active intervention for the first patient (November 11, 2014) and registration of the study (January 12, 2015) is explained in the Supplementary Appendix, available at NEJM.org.
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This recovery has been documented in various independent studies, including in participants with complete sensorimotor paralysis.
“This recovery has been documented in various independent studies, including in participants with complete sensorimotor paralysis5,6,30–34.”
From Walking naturally after spinal cord injury using a brain–spine interface (2023) · cites this paper as [32]
The Discussion reports that the two participants who recovered over-ground walking had partially spared sensation. The two participants with motor and sensory complete injuries did not achieve independent bilateral stepping or transition to over-ground walking. The paper therefore contradicts the claim if “this recovery” refers to walking. (LLM, conf=0.86)
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Experimental — accuracy not yet measuredThe delivery of epidural electrical stimulation over the lumbar spinal cord has enabled many individuals with spinal cord injury to regain adaptive control over the activity of otherwise paralysed muscles.
“The delivery of epidural electrical stimulation over the lumbar spinal cord has enabled many individuals with spinal cord injury to regain adaptive control over the activity of otherwise paralysed muscles.”
From Walking naturally after spinal cord injury using a brain–spine interface (2023) · cites this paper as [32]
The Results and Discussion (page numbers not supplied) report intention-dependent leg-muscle activity and walking with epidural stimulation in two of four participants; all four achieved some stimulation-dependent motor activity. The claim overgeneralizes this small study to “many individuals” and omits the intensive training used alongside stimulation. (LLM, conf=0.88)
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Epidural Spinal Cord Stimulation for Spinal Cord Injury in Humans: A Systematic Review
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Complications of epidural spinal stimulation: lessons from the past and alternatives for the future
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Spinal motor mapping by epidural stimulation of lumbosacral posterior roots in humans
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Posteroanterior cervical transcutaneous spinal stimulation targets ventral and dorsal nerve roots
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Functional Electrical Stimulation and the Modulation of the Axon Regeneration Program
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- Authors
- Angeli, C. A., Boakye, M., Morton, R. A., Vogt, J., Benton, K., Chen, Y., Ferreira, C. K., & Harkema, S. J.
- Affiliations
- University of Louisville (US)
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2018-09-27
- Volume
- 379
- Issue
- 13
- Pages
- 1244-1250
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2891480663
- Cited by
- 670
- References
- 21
- Citations by year
- 2026: 76 · 2025: 82 · 2024: 70 · 2023: 85 · 2022: 103 · 2021: 99 · 2020: 78 · 2019: 57 · 2018: 18
- FWCI
- 47.88
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Leona M. and Harry B. Helmsley Charitable Trust
- University of Louisville
- Topics
- Health Sciences › Medicine › Pathology and Forensic Medicine › Spinal Cord Injury Research
- Health Sciences › Medicine › Rehabilitation › Stroke Rehabilitation and Recovery
- Physical Sciences › Engineering › Biomedical Engineering › Prosthetics and Rehabilitation Robotics
- Keywords
- motor complete spinal cord injury, epidural spinal cord stimulation, overground walking, walking recovery, chronic spinal cord injury, core stability, spinal cord injury rehabilitation, thoracic trauma, standing training
- MeSH terms
- Adult, Chronic Disease, Electrodes, Implanted, Epidural Space, Exercise Therapy, Humans, Locomotion, Male, Spinal Cord Injuries, Walking, Recovery of Function, Spinal Cord Stimulation
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