{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,2]],"date-time":"2026-05-02T04:59:07Z","timestamp":1777697947205,"version":"3.51.4"},"reference-count":43,"publisher":"MDPI AG","issue":"22","license":[{"start":{"date-parts":[[2021,11,22]],"date-time":"2021-11-22T00:00:00Z","timestamp":1637539200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"German Federal Ministry of Economics and Energy","award":["ZF4171703TS7"],"award-info":[{"award-number":["ZF4171703TS7"]}]},{"name":"German Research Foundation and the Open Access Publication Fund of TU Berlin","award":["n\/a"],"award-info":[{"award-number":["n\/a"]}]},{"name":"BIH Charit\u00e9 Clinician Scientist Program","award":["Nikolaus Wenger"],"award-info":[{"award-number":["Nikolaus Wenger"]}]},{"name":"Volkswagen Foundation, Freigeist-Fellow","award":["Nikolaus Wenger"],"award-info":[{"award-number":["Nikolaus Wenger"]}]},{"name":"Austrian Science Fund (FWF)","award":["I 3837-B34"],"award-info":[{"award-number":["I 3837-B34"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Transcutaneous spinal cord stimulation (tSCS) is a promising intervention that can benefit spasticity control and augment voluntary movement in spinal cord injury (SCI) and multiple sclerosis. Current applications require expert knowledge and rely on the thorough visual analysis of electromyographic (EMG) responses from lower-limb muscles to optimize attainable treatment effects. Here, we devised an automated tSCS setup by combining an electrode array placed over low-thoracic to mid-lumbar vertebrae, synchronized EMG recordings, and a self-operating stimulation protocol to systematically test various stimulation sites and amplitudes. A built-in calibration procedure classifies the evoked responses as reflexes or direct motor responses and identifies stimulation thresholds as recommendations for tSCS therapy. We tested our setup in 15 individuals (five neurologically intact, five SCI, and five Parkinson\u2019s disease) and validated the results against blinded ratings from two clinical experts. Congruent results were obtained in 13 cases for electrode positions and in eight for tSCS amplitudes, with deviations of a maximum of one position and 5 to 10 mA in amplitude in the remaining cases. Despite these minor deviations, the calibration found clinically suitable tSCS settings in 13 individuals. In the remaining two cases, the automatic setup and both experts agreed that no reflex responses could be detected. The presented technological developments may facilitate the dissemination of tSCS into non-academic environments and broaden its use for diagnostic and therapeutic purposes.<\/jats:p>","DOI":"10.3390\/jcm10225464","type":"journal-article","created":{"date-parts":[[2021,12,1]],"date-time":"2021-12-01T01:43:22Z","timestamp":1638323002000},"page":"5464","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Algorithms for Automated Calibration of Transcutaneous Spinal Cord Stimulation to Facilitate Clinical Applications"],"prefix":"10.3390","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-5527-9895","authenticated-orcid":false,"given":"Christina","family":"Salchow-H\u00f6mmen","sequence":"first","affiliation":[{"name":"Department of Neurology, Charit\u00e9\u2013Universit\u00e4tsmedizin Berlin, 10117 Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0865-4418","authenticated-orcid":false,"given":"Thomas","family":"Schauer","sequence":"additional","affiliation":[{"name":"Control Systems Group, Technische Universit\u00e4t Berlin, 10587 Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Philipp","family":"M\u00fcller","sequence":"additional","affiliation":[{"name":"Control Systems Group, Technische Universit\u00e4t Berlin, 10587 Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4134-9060","authenticated-orcid":false,"given":"Andrea A.","family":"K\u00fchn","sequence":"additional","affiliation":[{"name":"Department of Neurology, Charit\u00e9\u2013Universit\u00e4tsmedizin Berlin, 10117 Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3156-6483","authenticated-orcid":false,"given":"Ursula S.","family":"Hofstoetter","sequence":"additional","affiliation":[{"name":"Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, 1090 Vienna, Austria"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0965-7530","authenticated-orcid":false,"given":"Nikolaus","family":"Wenger","sequence":"additional","affiliation":[{"name":"Department of Neurology, Charit\u00e9\u2013Universit\u00e4tsmedizin Berlin, 10117 Berlin, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,11,22]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1038\/s41586-018-0649-2","article-title":"Targeted neurotechnology restores walking in humans with spinal cord injury","volume":"563","author":"Wagner","year":"2018","journal-title":"Nature"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1244","DOI":"10.1056\/NEJMoa1803588","article-title":"Recovery of over-ground walking after chronic motor complete spinal cord injury","volume":"379","author":"Angeli","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1677","DOI":"10.1038\/s41591-018-0175-7","article-title":"Neuromodulation of lumbosacral spinal networks enables independent stepping after complete paraplegia","volume":"24","author":"Gill","year":"2018","journal-title":"Nat. Med."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1038\/sj.sc.3101615","article-title":"Stepping-like movements in humans with complete spinal cord injury induced by epidural stimulation of the lumbar cord: Electromyographic study of compound muscle action potentials","volume":"42","author":"Minassian","year":"2004","journal-title":"Spinal Cord."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1109\/TNSRE.2010.2054112","article-title":"Stimulation of the human lumbar spinal cord with implanted and surface electrodes: A computer simulation study","volume":"18","author":"Ladenbauer","year":"2010","journal-title":"IEEE Trans. Neural Syst. Rehabil. Eng."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"524","DOI":"10.1038\/sj.sc.3101040","article-title":"Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control of spasticity","volume":"38","author":"Pinter","year":"2000","journal-title":"Spinal Cord."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1394","DOI":"10.1093\/brain\/awu038","article-title":"Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans","volume":"137","author":"Angeli","year":"2014","journal-title":"Brain"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"284","DOI":"10.1007\/s13311-016-0421-y","article-title":"Targeting Lumbar Spinal Neural Circuitry by Epidural Stimulation to Restore Motor Function After Spinal Cord Injury","volume":"13","author":"Minassian","year":"2016","journal-title":"Neurotherapeutics"},{"key":"ref_9","first-page":"27","article-title":"Spinal cord stimulation for Parkinson\u2019s disease: A systematic review","volume":"39","author":"Ghilardi","year":"2015","journal-title":"Neurosurg. Rev."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1002\/mds.26850","article-title":"Spinal cord stimulation improves gait in patients with Parkinson\u2019s disease previously treated with deep brain stimulation","volume":"32","author":"Hamani","year":"2017","journal-title":"Mov. Disord."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e37727","DOI":"10.7554\/eLife.37727","article-title":"Effects of spinal cord stimulation on postural control in Parkinson\u2019s disease patients with freezing of gait","volume":"7","author":"Coelho","year":"2018","journal-title":"Elife"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"905","DOI":"10.3389\/fneur.2019.00905","article-title":"Spinal cord stimulation for freezing of gait: From bench to bedside","volume":"10","author":"Fonoff","year":"2019","journal-title":"Front. Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1002\/mds.28065","article-title":"Spinal Cord Stimulation for Very Advanced Parkinson\u2019s Disease: A 1-Year Prospective Trial","volume":"35","author":"Prasad","year":"2020","journal-title":"Mov. Disord."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"501","DOI":"10.1007\/978-3-319-72736-3_33","article-title":"Spinal cord stimulation as a neuromodulatory intervention for altered motor control following spinal cord injury","volume":"Volume 19","author":"Hofstoetter","year":"2018","journal-title":"Advanced Technologies for the Rehabilitation of Gait and Balance Disorders"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1125","DOI":"10.1113\/jphysiol.2007.128447","article-title":"Modulation of multisegmental monosynaptic responses in a variety of leg muscles during walking and running in humans","volume":"582","author":"Courtine","year":"2007","journal-title":"J. Physiol."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Dimitrijevic, M., Kakulas, B., McKay, W., and Vrbov\u00e1, G. (2011). Transcutaneous lumbar posterior root stimulation for motor control studies and modification of motor activity after spinal cord injury. Restorative Neurology of Spinal Cord Injury, Oxford University Press.","DOI":"10.1093\/acprof:oso\/9780199746507.001.0001"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Hofstoetter, U., Freundl, B., Binder, H., and Minassian, K. (2018). Common neural structures activated by epidural and transcutaneous lumbar spinal cord stimulation: Elicitation of posterior root-muscle reflexes. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0192013"},{"key":"ref_18","doi-asserted-by":"crossref","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":"ref_19","doi-asserted-by":"crossref","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":"ref_20","doi-asserted-by":"crossref","first-page":"17","DOI":"10.3389\/fneur.2017.00017","article-title":"Priming neural circuits to modulate spinal reflex excitability","volume":"8","author":"Estes","year":"2017","journal-title":"Front. Neurol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"333","DOI":"10.3389\/fnins.2017.00333","article-title":"Weight Bearing Over-ground Stepping in an Exoskeleton with Non-invasive Spinal Cord Neuromodulation after Motor Complete Paraplegia","volume":"11","author":"Gad","year":"2017","journal-title":"Front. Neurosci."},{"key":"ref_22","doi-asserted-by":"crossref","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":"ref_23","doi-asserted-by":"crossref","first-page":"481","DOI":"10.1089\/neu.2019.6588","article-title":"Transcutaneous Spinal Cord Stimulation Induces Temporary Attenuation of Spasticity in Individuals with Spinal Cord Injury","volume":"37","author":"Hofstoetter","year":"2020","journal-title":"J. Neurotrauma"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Meyer, C., Hofstoetter, U.S., Hubli, M., Hassani, R.H., Rinaldo, C., Curt, A., and Bolliger, M. (2020). Immediate Effects of Transcutaneous Spinal Cord Stimulation on Motor Function in Chronic, Sensorimotor Incomplete Spinal Cord Injury. J. Clin. Med., 9.","DOI":"10.3390\/jcm9113541"},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Hofstoetter, U., Freundl, B., Lackner, P., and Binder, H. (2021). Transcutaneous Spinal Cord Stimulation Enhances Walking Performance and Reduces Spasticity in Individuals with Multiple Sclerosis. Brain Sci., 11.","DOI":"10.3390\/brainsci11040472"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"103009","DOI":"10.1016\/j.msard.2021.103009","article-title":"Transcutaneous spinal cord stimulation improves postural stability in individuals with multiple sclerosis","volume":"52","author":"Roberts","year":"2021","journal-title":"Mult. Scler. Relat. Disord."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"101930","DOI":"10.1016\/j.isci.2020.101930","article-title":"Spinal motor mapping by epidural stimulation of lumbosacral posterior roots in humans","volume":"24","author":"Hofstoetter","year":"2021","journal-title":"iScience"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"394","DOI":"10.1038\/sj.sc.3101038","article-title":"Epidural electric stimulation of posterior structures of the human lumbar spinal cord: 1. muscle twitches\u2014A functional method to define the site of stimulation","volume":"38","author":"Murg","year":"2000","journal-title":"Spinal Cord."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1002\/mus.20700","article-title":"Posterior root-muscle reflexes elicited by transcutaneous stimulation of the human lumbosacral cord","volume":"35","author":"Minassian","year":"2007","journal-title":"Muscle Nerv."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"644","DOI":"10.1111\/j.1525-1594.2008.00616.x","article-title":"Modification of reflex responses to lumbar posterior root stimulation by motor tasks in healthy subjects","volume":"32","author":"Hofstoetter","year":"2008","journal-title":"Artif. Organs"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1451","DOI":"10.1089\/neu.2018.5921","article-title":"Electrophysiological Guidance of Epidural Electrode Array Implantation over the Human Lumbosacral Spinal Cord to Enable Motor Function after Chronic Paralysis","volume":"36","author":"Calvert","year":"2019","journal-title":"J. Neurotrauma"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1038\/sj.sc.3101039","article-title":"Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 2. quantitative analysis by computer modeling","volume":"38","author":"Rattay","year":"2000","journal-title":"Spinal Cord."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"19326","DOI":"10.1523\/JNEUROSCI.1688-13.2013","article-title":"A computational model for epidural electrical stimulation of spinal sensorimotor circuits","volume":"33","author":"Capogrosso","year":"2013","journal-title":"J. Neurosci."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1212\/WNL.17.5.427","article-title":"Parkinsonism: Onset, progression, and mortality","volume":"17","author":"Hoehn","year":"1967","journal-title":"Neurology"},{"key":"ref_35","unstructured":"Salchow-H\u00f6mmen, C., Dikau, C., Mueller, P., Hofstoetter, U., K\u00fchn, A., Schauer, T., and Wenger, N. (2019, January 24\u201328). Characterization of optimal electrode configurations for transcutaneous spinal cord stimulation. Proceedings of the IFESS Conference at Rehab Week, Toronto, ON, Canada."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1364","DOI":"10.1152\/japplphysiol.01128.2014","article-title":"Spinal segment-specific transcutaneous stimulation differentially shapes activation pattern among motor pools in humans","volume":"118","author":"Sayenko","year":"2015","journal-title":"J. Appl. Physiol."},{"key":"ref_37","unstructured":"Sojka, M., and P\u00ed\u0161a, P. (2014, January 12\u201313). Usable Simulink Embedded Coder Target for Linux. Proceedings of the 16th Real Time Linux Workshop, D\u00fcsseldorf, Germany."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Estes, S., Zarkou, A., Hope, J.M., Suri, C., and Field-Fote, E.C. (2021). Combined Transcutaneous Spinal Stimulation and Locomotor Training to Improve Walking Function and Reduce Spasticity in Subacute Spinal Cord Injury: A Randomized Study of Clinical Feasibility and Efficacy. J. Clin. Med., 10.","DOI":"10.3390\/jcm10061167"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"731","DOI":"10.1007\/s00702-007-0001-8","article-title":"Pedunculopontine nucleus deep brain stimulation changes spinal cord excitability in Parkinson\u2019s disease patients","volume":"115","author":"Pierantozzi","year":"2008","journal-title":"J. Neural. Transm."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"667","DOI":"10.1111\/apha.12233","article-title":"Input-output characteristics of soleus homonymous Ia afferents and corticospinal pathways during upright standing differ between young and elderly adults","volume":"210","author":"Baudry","year":"2014","journal-title":"Acta Physiol."},{"key":"ref_41","doi-asserted-by":"crossref","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\u2013injured individuals","volume":"30","author":"Minassian","year":"2016","journal-title":"Neurorehabil. Neural. Repair."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1038\/s41394-020-00359-1","article-title":"Feasibility and utility of transcutaneous spinal cord stimulation combined with walking-based therapy for people with motor incomplete spinal cord injury","volume":"6","author":"McHugh","year":"2020","journal-title":"Spinal Cord. Ser. Cases"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Danner, S., Krenn, M., Hofstoetter, U., Toth, A., Mayr, W., and Minassian, K. (2016). Body position influences which neural structures are recruited by lumbar transcutaneous spinal cord stimulation. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0147479"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/22\/5464\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T07:34:18Z","timestamp":1760168058000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/10\/22\/5464"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,11,22]]},"references-count":43,"journal-issue":{"issue":"22","published-online":{"date-parts":[[2021,11]]}},"alternative-id":["jcm10225464"],"URL":"https:\/\/doi.org\/10.3390\/jcm10225464","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,11,22]]}}}