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Paired associative stimulation after spinal cord injury: Who should undergo?

Introduction/Background Paired associative stimulation (PAS) combines electrical stimulation of peripheral nerves (ESPN) with transcranial magnetic stimulation (TMS) and is believed to induce plastic changes in the human corticospinal tract after spinal cord injury (SCI). The aim of the present study was to investigate the advantages of PAS added to the general rehabilitation protocol for chronic SCI. Material and method The study was monocentric sham-controlled. Patients with lower paraplegia 3–12 months after the trauma were randomly divided into study and control groups: 11 and 9 respectively. TMS was delivered over vertex using a round coil with 90–100% absolute intensity. ESPN of both N. peroneous and N. tibialis was performed with supramaximal intensity at fossa poplitea for 5 minutes for each nerve. The interval between TMS and ESPN was 0.2ms. The intervention consisted 30 sessions of 1 Hz PAS in total. Results After the intervention, the improvement of motor and sensory function (via ASIA impairment scale) was observed in both groups but the intergroup difference was insignificant (Mann-Whitney U test, P = 0.0675). Spasticity (via modified Ashworth scale) was not changed significantly but 4 patients noticed more uncontrolled movements. Noticeably, patients with no peripheral M-response at the beginning do not demonstrated any improvements. The best functional outcome was found into patients with preserved MEP in the study group. Two patients with no MEP at the beginning from the study group showed unstable MEP after the month. Conclusion PAS could be seen as an additional tool to facilitate the recovery after chronic SCI. Patients with preserved MEP may benefit more from this technique. On the other hand, the absence of M response could be considered as an exclusion criterion while the selection of individuals for PAS. The choice of stimulation protocols is still arguable that can lead to diverse and controversial results.