The Combined Use of Non-Invasive Neurostimulation with Interactive Digital Technologies in Spinal Cord Injury Rehabilitation: A Scoping Review.
Samuel David Williamson, Magnus Møller Andersen, Anders Orup Aaby and 2 others
Combining electrical stimulation with VR or games showed preliminary gains in gross-motor function and patient engagement across 12 small SCI studies, but the authors state the evidence is too weak to support any clinical recommendation.
Key findings
1Preliminary functional improvements were seen in gross-motor and dynamic tasks (cycling, standing, balance, upper-limb dexterity), but gains in fine-motor skills and static postural control were limited or absent.
2In one 52-week BCI-FES-VR study, 2 of 4 participants recovered voluntary muscle contractions below the injury level sufficient to warrant reclassification from AIS A/B to AIS C.
3The authors conclude that, given the low evidentiary standard of the included studies (8 of 12 had no control group, samples of 1–13), the findings are insufficient to support clinical recommendations.
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What it does not show
Eight of the 12 included studies had no independent control group, so it is impossible to separate the effect of the combined intervention from natural recovery, practice effects, or the stimulation alone. Several participants were in the sub-acute phase (20 days to 12 months post-injury), a period when spontaneous motor recovery is expected, making it unclear how much of the observed gain is attributable to the intervention. Individual study samples were very small (1 to 13 participants), and the total unique participant count across all 12 studies was 51. Improvements were largely restricted to the specific gross-motor or dynamic tasks that were trained; fine-motor skills and static postural control showed little or no significant change. No included study provided direct physiological confirmation of neuroplasticity (no brain or spinal cord imaging, no motor evoked potentials); functional and biomechanical gains were used as proxies. Psychological benefits were reported mostly anecdotally; only a few studies used validated scales. The review was limited to studies published in English, Danish, Norwegian, or Swedish, potentially excluding relevant work in other languages. No formal risk-of-bias assessment was performed, consistent with scoping review methodology, so the quality of individual studies was not systematically appraised. One crossover trial acknowledged carryover effects (baseline scores elevated after the first treatment), and the authors note that washout periods in future crossover designs need to be longer.
Declared interests
The authors declare no conflicts of interest. Financial support was provided by the Danish Victims Fund. The authors state that the fund's views do not necessarily reflect in the work and that execution, content, and results are the sole responsibility of the authors.
The easy way to misread this
Do not read the functional improvements (cycling power, standing weight-bearing, upper-limb dexterity) as evidence that adding VR or games to FES makes the rehabilitation work better. 8 of the 12 studies had no control group, several participants were in the sub-acute phase where spontaneous recovery is expected, and the authors themselves state the findings are insufficient to support clinical recommendations. The one AIS reclassification came from a 4-person, non-randomised study with sub-acute participants, and the authors note the gain cannot be definitively attributed to the intervention alone.
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