{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T06:04:04Z","timestamp":1790661844126,"version":"4.1.0"},"reference-count":80,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"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. Pain Res."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Conventional spinal cord stimulation (SCS) primarily modulates neural pain-processing pathways but may not address persistent paraspinal muscle dysfunction associated with chronic back pain. MuscleSCS extends the therapeutic scope of implanted SCS systems by applying low-frequency stimulation through the existing epidural electrode to generate objectively verifiable paraspinal muscle activity. This activity is consistent with spinal motor pathway recruitment, although the specific neural pathways involved remain undetermined.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To describe the conceptual basis, technical implementation, programming workflow, validation, anticipated results, and biological rationale of MuscleSCS as a method for combined neural and muscular neuromodulation.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Low-frequency stimulation (typically 2\u20138\u2005Hz, most commonly 4\u20138\u2005Hz) is delivered through selected electrode contacts. Programs are optimized using contact screening, amplitude titration, patient feedback, visual and haptic assessment, surface electromyography, and muscle ultrasound. Programming is technically similar to conventional SCS and typically requires 15\u201320\u2005min.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Anticipated results<\/jats:title>\n                    <jats:p>Previous clinical studies demonstrated technical feasibility, electrophysiologically verifiable muscle activation, ultrasound-confirmed activation of deep paraspinal muscles, and additional pain relief when MuscleSCS was combined with BurstDR SCS. The goal is comfortable muscle modulation rather than muscle strengthening.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>MuscleSCS provides a reproducible framework for spinally mediated muscle modulation that may complement conventional neural neuromodulation and improve pain relief. The underlying downstream mechanotransductive and immunomodulatory tissue responses provide a biologically plausible mechanistic framework derived from established skeletal-muscle mechanobiology but remain to be specifically validated for MuscleSCS.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpain.2026.1954865","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T05:46:10Z","timestamp":1790660770000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["MuscleSCS: a standardized programming framework combining neural neuromodulation and spinally mediated paraspinal muscle modulation"],"prefix":"10.3389","volume":"7","author":[{"given":"Matthias Hubert","family":"Morgalla","sequence":"first","affiliation":[{"name":"INST-Institute for Neuromodulative Pain Therapy","place":["Sigmaringen, Germany"]},{"name":"Medical Faculty, University of Tuebingen","place":["Tuebingen, Germany"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,29]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"363","DOI":"10.1056\/NEJM200102013440508","article-title":"Low back pain","volume":"344","author":"Deyo","year":"2001","journal-title":"N Engl J Med"},{"key":"B2","doi-asserted-by":"publisher","first-page":"2356","DOI":"10.1016\/S0140-6736(18)30480-X","article-title":"What low back pain is and why we need to pay attention","volume":"391","author":"Hartvigsen","year":"2018","journal-title":"Lancet"},{"key":"B3","doi-asserted-by":"publisher","first-page":"736","DOI":"10.1016\/S0140-6736(16)30970-9","article-title":"Non-specific low back pain","volume":"389","author":"Maher","year":"2017","journal-title":"Lancet"},{"key":"B4","doi-asserted-by":"publisher","first-page":"CD014789","DOI":"10.1002\/14651858.CD014789.pub2","article-title":"Spinal cord stimulation for low back pain","volume":"3","author":"Traeger","year":"2023","journal-title":"Cochrane Database Syst Rev"},{"key":"B5","doi-asserted-by":"publisher","first-page":"272","DOI":"10.3390\/jcm11010272","article-title":"The challenge of converting \u201cfailed spinal cord stimulation syndrome\u201d back to clinical success, using SCS reprogramming as salvage therapy, through neurostimulation adapters combined with 3D-computerized pain mapping assessment: a real-life retrospective study","volume":"11","author":"Rigoard","year":"2022","journal-title":"J Clin Med"},{"key":"B6","doi-asserted-by":"publisher","first-page":"S47","DOI":"10.1093\/pm\/pnz046","article-title":"Burst spinal cord stimulation: a systematic review and pooled analysis of real-world evidence and outcomes data","volume":"20","author":"Chakravarthy","year":"2019","journal-title":"Pain Med"},{"key":"B7","doi-asserted-by":"publisher","first-page":"56","DOI":"10.1111\/ner.12698","article-title":"Success using neuromodulation with BURST (SUNBURST) study: results from a prospective, randomized controlled trial using a novel burst waveform","volume":"21","author":"Deer","year":"2018","journal-title":"Neuromodulation"},{"key":"B8","doi-asserted-by":"publisher","first-page":"1387","DOI":"10.1016\/j.neurom.2023.07.009","article-title":"Treatment of refractory low back pain using passive recharge burst in patients without options for corrective surgery: findings and results from the DISTINCT study, a prospective randomized multicenter controlled trial","volume":"26","author":"Deer","year":"2023","journal-title":"Neuromodulation"},{"key":"B9","doi-asserted-by":"publisher","first-page":"1953","DOI":"10.3390\/healthcare10101953","article-title":"Spinal cord stimulation in chronic low back pain syndrome: mechanisms of modulation, technical features and clinical application","volume":"10","author":"Guzzi","year":"2022","journal-title":"Healthcare (Basel)"},{"key":"B10","doi-asserted-by":"publisher","first-page":"152","DOI":"10.1111\/ner.12116","article-title":"Burst spinal cord stimulation evaluated in patients with failed back surgery syndrome and painful diabetic neuropathy","volume":"17","author":"De Vos","year":"2014","journal-title":"Neuromodulation"},{"key":"B11","doi-asserted-by":"publisher","first-page":"2050312120951369","DOI":"10.1177\/2050312120951369","article-title":"10 Khz spinal cord stimulation for the treatment of chronic back and\/or leg pain: summary of clinical studies","volume":"8","author":"Luecke","year":"2020","journal-title":"SAGE Open Med"},{"key":"B12","doi-asserted-by":"publisher","first-page":"502","DOI":"10.1111\/papr.13324","article-title":"Is it possible to generate an additional pleasant and pain-relieving muscle stimulation when using low-frequency spinal cord stimulation (SCS) for the treatment of lower back pain? 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