{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T06:07:43Z","timestamp":1779084463721,"version":"3.51.4"},"reference-count":44,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T00:00:00Z","timestamp":1779062400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Hum. Neurosci."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Spinal cord injury (SCI) causes significant motor, sensory, and autonomic dysfunction, with gait recovery being a primary rehabilitation goal. Transcutaneous spinal cord stimulation (tSCS) combined with robotic-assisted gait training (RAGT) represents a promising synergistic approach to enhance motor recovery, though evidence for overground exoskeletal training with tSCS remains limited.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>We report a 40-year-old male with chronic incomplete traumatic SCI (T5, ASIA D) who underwent a two-phase intervention: Phase I consisted of 16 sessions of overground RAGT using the EksoGT exoskeleton, followed by Phase II comprising 16 sessions of RAGT combined with tSCS using the ARC-EX system. Comprehensive assessments included ISNCSCI neurological examination, 10-meter walk test (10MWT), spatiotemporal gait analysis, surface electromyography (EMG), and central motor conduction time (CMCT).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>The participant demonstrated substantial improvements in gait speed from 0.26\u202fm\/s at baseline to 0.41\u202fm\/s at four-week follow-up (\u0394\u202f=\u202f+0.15\u202fm\/s), exceeding the minimal clinically important difference of 0.13\u202fm\/s. Lower Extremity Motor Score improved from 35\/50 to 42\/50, with notable distal lower limb gains. Cadence increased from 31.53 to 39.74 steps\/min (right) and 33.29 to 38.67 steps\/min (left), while stride length improved from 0.91\u202fm to 1.17\u202fm (right) and 0.95\u202fm to 1.17\u202fm (left). EksoGT MinAssist values decreased from an average of 61 (Phase I) to 50 (Phase II), indicating greater active participant engagement with tSCS. EMG recordings demonstrated enhanced neuromuscular activation following tSCS, with more organized muscle recruitment patterns. CMCT decreased from 21.9\u202fms to 19.7\u202fms on the right side, suggesting improved corticospinal tract conduction. EQ-VAS improved from 80 to 90. No adverse events were reported.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This is the first reported case integrating tSCS with overground exoskeletal training in SCI rehabilitation. The combination of tSCS and RAGT appears safe and may provide synergistic benefits for motor recovery, particularly when conventional therapy reaches a plateau. These findings support further investigation through larger controlled studies to validate optimal stimulation protocols and generalizability.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fnhum.2026.1795068","type":"journal-article","created":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T05:42:10Z","timestamp":1779082930000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Case Report: Efficacy of transcutaneous spinal cord stimulation combined with overground robotic-assisted gait training in chronic incomplete spinal cord injury"],"prefix":"10.3389","volume":"20","author":[{"given":"Gobinathan","family":"Chandran","sequence":"first","affiliation":[{"name":"Division of Rehabilitation Medicine, Department of Medicine, National University Hospital","place":["Singapore, Singapore"]},{"name":"Department of Rehabilitation Medicine, Alexandra Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nur Shafawati","family":"Kamsani","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation, Alexandra Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ning","family":"Tang","sequence":"additional","affiliation":[{"name":"Division of Rehabilitation Medicine, Department of Medicine, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hwa Sen","family":"Lai","sequence":"additional","affiliation":[{"name":"Division of Rehabilitation Medicine, Department of Medicine, National University Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tracy","family":"Ong","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation, Alexandra Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Su-Ann","family":"Cheng","sequence":"additional","affiliation":[{"name":"Department of Rehabilitation Medicine, Tan Tock Seng Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jeong Hoon","family":"Lim","sequence":"additional","affiliation":[{"name":"Division of Rehabilitation Medicine, Department of Medicine, National University Hospital","place":["Singapore, Singapore"]},{"name":"Department of Rehabilitation Medicine, Alexandra Hospital","place":["Singapore, Singapore"]},{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ravi","family":"Shankar","sequence":"additional","affiliation":[{"name":"Medical Affairs \u2013 Research Innovation & Enterprise, Alexandra Hospital","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Effie","family":"Chew","sequence":"additional","affiliation":[{"name":"Division of Rehabilitation Medicine, Department of Medicine, National University Hospital","place":["Singapore, Singapore"]},{"name":"Department of Rehabilitation Medicine, Alexandra Hospital","place":["Singapore, Singapore"]},{"name":"Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore","place":["Singapore, Singapore"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2026,5,18]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1186\/s12984-018-0453-0","article-title":"Overground walking with a robotic exoskeleton elicits trunk muscle activity in people with high-thoracic motor-complete spinal cord injury","volume":"15","author":"Alamro","year":"2018","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref2","doi-asserted-by":"publisher","first-page":"582","DOI":"10.1080\/10790268.2021.2000200","article-title":"Transcutaneous spinal cord stimulation effects on spasticity in patients with spinal cord injury: a systematic review","volume":"46","author":"Alashram","year":"2023","journal-title":"J. Spinal Cord Med."},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1371","DOI":"10.1089\/neu.2004.21.1371","article-title":"Targeting recovery: priorities of the spinal cord-injured population","volume":"21","author":"Anderson","year":"2004","journal-title":"J. Neurotrauma"},{"key":"ref9002","doi-asserted-by":"publisher","first-page":"106","DOI":"10.1038\/s41393-017-0013-7","article-title":"Gait training after spinal cord injury: safety, feasibility and gait function following 8 weeks of training with the exoskeletons from Ekso Bionics","volume":"56","author":"Bach Baunsgaard","year":"2018","journal-title":"Spinal Cord"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"2633","DOI":"10.1523\/JNEUROSCI.2374-19.2020","article-title":"Cortical and subcortical effects of transcutaneous spinal cord stimulation in humans with tetraplegia","volume":"40","author":"Benavides","year":"2020","journal-title":"J. Neurosci."},{"key":"ref5","doi-asserted-by":"publisher","first-page":"15","DOI":"10.1186\/s12984-025-01545-8","article-title":"Transcutaneous spinal cord stimulation combined with robotic-assisted body weight-supported treadmill training enhances motor score and gait recovery in incomplete spinal cord injury: a double-blind randomized controlled clinical trial","volume":"22","author":"Comino-Su\u00e1rez","year":"2025","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref6","doi-asserted-by":"publisher","first-page":"500","DOI":"10.1016\/j.clinbiomech.2014.04.004","article-title":"Gait adaptation during walking on an inclined pathway following spinal cord injury","volume":"29","author":"Desrosiers","year":"2014","journal-title":"Clin. Biomech. (Bristol)"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"895","DOI":"10.1097\/BRS.0000000000001939","article-title":"Use of central motor conduction time and spinal cord evoked potentials in the electrophysiological assessment of compressive cervical myelopathy","volume":"42","author":"Fujimoto","year":"2017","journal-title":"Spine (Phila Pa 1976)"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1016\/j.jocn.2021.09.032","article-title":"Radiological factors associated with the severity of corticospinal tract dysfunctions for cervical spondylotic myelopathy: an analysis of the central motor conduction time and kinematic CT myelography","volume":"94","author":"Funaba","year":"2021","journal-title":"J. Clin. Neurosci."},{"key":"ref9","doi-asserted-by":"publisher","first-page":"1968","DOI":"10.1089\/neu.2015.4008","article-title":"Noninvasive reactivation of motor descending control after paralysis","volume":"32","author":"Gerasimenko","year":"2015","journal-title":"J. Neurotrauma"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1186\/s12984-023-01158-z","article-title":"Exoskeleton-based training improves walking independence in incomplete spinal cord injury patients: results from a randomized controlled trial","volume":"20","author":"Gil-Agudo","year":"2023","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref11","doi-asserted-by":"publisher","DOI":"10.1515\/bmt-2013-4014","article-title":"Effects of transcutaneous spinal cord stimulation on voluntary locomotor activity in an incomplete spinal cord injured individual","volume":"58","author":"Hofstoetter","year":"2013","journal-title":"Biomed Tech (Berl)"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"E176","DOI":"10.1111\/aor.12615","article-title":"Augmentation of voluntary locomotor activity by transcutaneous spinal cord stimulation in motor-incomplete spinal cord-injured individuals","volume":"39","author":"Hofstoetter","year":"2015","journal-title":"Artif. Organs"},{"key":"ref9005","doi-asserted-by":"publisher","first-page":"202","DOI":"10.1179\/2045772313Y.0000000149","article-title":"Modification of spasticity by transcutaneous spinal cord stimulation in individuals with incomplete spinal cord injury","volume":"37","author":"Hofstoetter","year":"2014","journal-title":"J. Spinal Cord. Med."},{"key":"ref13","doi-asserted-by":"publisher","first-page":"727","DOI":"10.2165\/00007256-200434110-00003","article-title":"Exercise recommendations for individuals with spinal cord injury","volume":"34","author":"Jacobs","year":"2004","journal-title":"Sports Med."},{"key":"ref14","doi-asserted-by":"publisher","first-page":"455","DOI":"10.20944\/preprints202308.1557.v1","article-title":"Exploring the quality of life of people with incomplete spinal cord injury who can ambulate","volume":"3","author":"Jeawon","year":"2023","journal-title":"Disabilities"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"535","DOI":"10.1179\/204577211X13207446293695","article-title":"International standards for neurological classification of spinal cord injury (revised 2011)","volume":"34","author":"Kirshblum","year":"2011","journal-title":"J. Spinal Cord Med."},{"key":"ref16","doi-asserted-by":"publisher","first-page":"1267","DOI":"10.1089\/neu.2020.7473","article-title":"Characterizing natural recovery after traumatic spinal cord injury","volume":"38","author":"Kirshblum","year":"2021","journal-title":"J. Neurotrauma"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"e102313","DOI":"10.1371\/journal.pone.0102313","article-title":"Transpinal and transcortical stimulation alter corticospinal excitability and increase spinal output","volume":"9","author":"Knikou","year":"2014","journal-title":"PLoS One"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1310\/sci1301-32","article-title":"A systematic review of the efficacy of gait rehabilitation strategies for spinal cord injury","volume":"13","author":"Lam","year":"2007","journal-title":"Top. Spinal Cord Inj. Rehabil."},{"key":"ref19","doi-asserted-by":"publisher","first-page":"246","DOI":"10.1038\/sj.sc.3102134","article-title":"A systematic review of functional ambulation outcome measures in spinal cord injury","volume":"46","author":"Lam","year":"2008","journal-title":"Spinal Cord"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"1753","DOI":"10.2147\/CIA.S270407","article-title":"Reference values of gait speed and gait spatiotemporal parameters for a south east Asian population: the Yishun study","volume":"15","author":"Lau","year":"2020","journal-title":"Clin. Interv. Aging"},{"key":"ref21","volume-title":"StatPearls","author":"Margetis","year":"2025"},{"key":"ref9004","doi-asserted-by":"publisher","first-page":"110","DOI":"10.1310\/sci2102-110","article-title":"Time and effort required by persons with spinal cord injury to learn to use a powered exoskeleton for assisted walking","volume":"21","author":"Kozlowski","year":"2015","journal-title":"Top. Spinal. Cord. Inj. Rehabil."},{"key":"ref9006","doi-asserted-by":"publisher","first-page":"3","DOI":"10.1177\/1545968319893298","article-title":"Transcutaneous spinal cord stimulation and motor rehabilitation in spinal cord injury: a systematic review","volume":"34","author":"Meg\u00eda Garc\u00eda","year":"2020","journal-title":"Neurorehabilitation and Neural Repair"},{"key":"ref9003","doi-asserted-by":"publisher","first-page":"101805","DOI":"10.1016\/j.xcrm.2024.101805","article-title":"Transcutaneous spinal cord stimulation neuromodulates pre-and postsynaptic inhibition in the control of spinal spasticity","volume":"5","author":"Minassian","year":"2024","journal-title":"Cell. Rep. Med."},{"key":"ref22","doi-asserted-by":"publisher","first-page":"233","DOI":"10.1177\/1545968315591706","article-title":"Spinal rhythm generation by step-induced feedback and transcutaneous posterior root stimulation in complete spinal cord-injured individuals","volume":"30","author":"Minassian","year":"2016","journal-title":"Neurorehabil. Neural Repair"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"787690","DOI":"10.3389\/fnins.2021.787690","article-title":"Sensory circuit remodeling and movement recovery after spinal cord injury","volume":"15","author":"Moreno-Lopez","year":"2021","journal-title":"Front. Neurosci."},{"key":"ref24","doi-asserted-by":"publisher","first-page":"1276","DOI":"10.1038\/s41591-024-02940-9","article-title":"Non-invasive spinal cord electrical stimulation for arm and hand function in chronic tetraplegia: a safety and efficacy trial","volume":"30","author":"Moritz","year":"2024","journal-title":"Nat. Med."},{"key":"ref25","volume-title":"Kinesiology of the Musculoskeletal System: Foundations for Rehabilitation","author":"Neumann","year":"2017"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"171","DOI":"10.5535\/arm.230039","article-title":"Robot-assisted gait training in individuals with spinal cord injury: a systematic review and Meta-analysis of randomized controlled trials","volume":"48","author":"Park","year":"2024","journal-title":"Ann. Rehabil. Med."},{"key":"ref27","volume-title":"Gait Analysis: Normal and Pathological Function","author":"Perry","year":"2010"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"2540","DOI":"10.1089\/neu.2017.5584","article-title":"Trunk stability enabled by noninvasive spinal electrical stimulation after spinal cord injury","volume":"35","author":"Rath","year":"2018","journal-title":"J. Neurotrauma"},{"key":"ref9015","doi-asserted-by":"publisher","first-page":"e0278425","DOI":"10.1371\/journal.pone.0278425","article-title":"Effects of non-invasive spinal cord stimulation on lower urinary tract, bowel, and sexual functions in individuals with chronic motor-complete spinal cord injury: protocol for a pilot clinical trial","volume":"17","author":"Samejima","year":"2022","journal-title":"PLoS One."},{"key":"ref29","doi-asserted-by":"publisher","first-page":"1435","DOI":"10.1089\/neu.2018.5956","article-title":"Self-assisted standing enabled by non-invasive spinal stimulation after spinal cord injury","volume":"36","author":"Sayenko","year":"2019","journal-title":"J. Neurotrauma"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"e80995","DOI":"10.2196\/80995","article-title":"Effectiveness of transcutaneous spinal cord stimulation for lower limb rehabilitation in spinal cord injury: protocol for a systematic review and Meta-analysis","volume":"14","author":"Shankar","year":"","journal-title":"JMIR Res. Protoc."},{"key":"ref31","doi-asserted-by":"publisher","first-page":"30","DOI":"10.1186\/s12984-025-01775-w","article-title":"Effectiveness of transcutaneous spinal cord stimulation for lower limb rehabilitation in spinal cord injury: a systematic review","volume":"23","author":"Shankar","year":"","journal-title":"J. Neuroeng. Rehabil."},{"key":"ref9008","doi-asserted-by":"publisher","first-page":"2256","DOI":"10.1109\/TBME.2022.3140258","article-title":"Detection of freezing of gait using convolutional neural networks and data from lower limb motion sensors","volume":"69","author":"Shi","year":"2022","journal-title":"IEEE. Trans. Biomed. Eng."},{"key":"ref9007","doi-asserted-by":"publisher","first-page":"5410","DOI":"10.1109\/EMBC44109.2020.9175687","article-title":"Convolutional neural network for freezing of gait detection leveraging the continuous wavelet transform on lower extremities wearable sensors data.","author":"Shi","year":"2020","journal-title":"2020 42nd Annual International Conference of the IEEE Engineering in Medicine & Biology Society (EMBC) (IEEE)"},{"key":"ref9001","doi-asserted-by":"publisher","first-page":"1144","DOI":"10.1016\/j.neurom.2025.01.005","article-title":"Safety and Effectiveness of Multisite Transcutaneous Spinal Cord Stimulation Combined With Activity-Based Therapy When Delivered in a Community Rehabilitation Setting: A Real-World Pilot Study","volume":"28","author":"Suggitt","year":"2025","journal-title":"Neuromodulation"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"34","DOI":"10.3390\/biomedicines11010034","article-title":"Combined transcutaneous electrical spinal cord stimulation and task-specific rehabilitation improves trunk and sitting functions in people with chronic tetraplegia","volume":"11","author":"Tharu","year":"2022","journal-title":"Biomedicine"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"375","DOI":"10.1016\/b978-0-444-53497-2.00031-0","article-title":"Central motor conduction time","volume":"116","author":"Udupa","year":"2013","journal-title":"Handb. Clin. Neurol."},{"key":"ref34","doi-asserted-by":"publisher","first-page":"98","DOI":"10.1310\/sci1301-98","article-title":"Cardiovascular health and exercise rehabilitation in spinal cord injury","volume":"13","author":"Warburton","year":"2007","journal-title":"Top. Spinal Cord Inj. Rehabil."},{"key":"ref35","volume-title":"Minimum Technical Standards and Recommendations for spinal cord Injury Management in Emergencies","year":"2025"}],"container-title":["Frontiers in Human Neuroscience"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnhum.2026.1795068\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T05:42:12Z","timestamp":1779082932000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fnhum.2026.1795068\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,18]]},"references-count":44,"alternative-id":["10.3389\/fnhum.2026.1795068"],"URL":"https:\/\/doi.org\/10.3389\/fnhum.2026.1795068","relation":{},"ISSN":["1662-5161"],"issn-type":[{"value":"1662-5161","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,18]]},"article-number":"1795068"}}