Non-invasive electrode stimulation gives hope to spinal cord injury patients with partial paralysis
SINGAPORE – Last year, while clearing debris from the Moringa tree in his backyard, Mr Reuben T. Sreetharan fell, landing hard on his feet before collapsing into a seated position. There was no pain, but he couldn't move his legs.
At the hospital, the 53-year-old businessman learnt that the fall had injured his spinal cord in the middle back, which partially severed his brain's connection to the body from below that area. His hospital stay lasted five months, during which he had to learn how to live without the use of his lower body.
In Singapore, the National Neuroscience Institute (NNI) and Tan Tock Seng Hospital (TTSH) have previously said they see approximately 100 new cases of spinal cord injury (SCI) annually, while the hospitals in the National University Health System cluster manage an average of 35 new inpatient cases every year.
Falls are a leading cause of this life-altering condition, especially in older adults, who may be at an increased risk of premature death due to injury-related complications.
There is no known cure for SCI, which results in either complete or incomplete loss of sensory and/or motor functions below the injury level, but researchers around the world and here are exploring new treatments, including therapies and advanced assistive technologies.
A promising research area is electrode stimulation, which involves delivering electrical pulses either through electrodes placed on the skin known as transcutaneous spinal cord stimulation, or surgically implanted near the spinal cord.
At Alexandra Hospital (AH), Clinical Assistant Professor Gobinathan Chandran, a consultant in rehabilitation medicine, started a new trial that uses non-invasive electrode stimulation with robotic gait training to enhance mobility in SCI patients.
In November 2024, Mr Sreetharan became the first of six participants in the trial, and underwent 32 sessions of therapy using a wearable robotic device that supports and assists movement known as the exoskeleton, including 16 done with electrode stimulation.
It was not till the 25th session that he started to notice subtle changes. He said he can now feel his feet pressing on the footrests of his wheelchair, his hamstrings, and even his glutes, when previously he felt like he was living on a cloud.
Mr Sreetharan is hoping the therapy can become a clinical service, as Dr Chandran had said that overseas studies done on the use of non-invasive electrical stimulation for upper limb mobility showed that at least 60 sessions are needed to show sustained functional improvements.
'I would say that, frankly, I've not given up. I think that's what keeps me going,' he said.
So far, early results from the trial are promising – participants were able to take more steps per minute with the stimulation when using a robotic wearable device to assist with the walking, and this led to improved walking speed, said Dr Chandran.
'Those who are severely injured might not be able to walk at the end of the day, but if they're able to improve their truncal control, are better in transferring on their own and all that, these are small things that really will improve their quality of life,' he told The Straits Times .
'If they're already a walker, then we want them to walk with a better gait, or even independently.'
Mr Reuben T. Sreetharan can now feel his feet pressing on the footrests of his wheelchair, his hamstrings, and even his glutes, when previously he felt like he was living on a cloud.
ST PHOTO: SHINTARO TAY
AH has recruited four patients for the first study of six patients funded by a NUHS $150,000 seed grant and one patient for the second study of six patients with partial paralysis of four limbs. As there is no grant for the latter, participants have to pay $180 for the physiotherapy for each session.
The trials are for patients who were diagnosed with a traumatic and incomplete SCI between six months and five years ago and cannot walk independently.
Dr Chandran said the aim is to use electrodes to stimulate the surviving dormant nerves of patients with an incomplete injury to improve their functional mobility.
Likening the spinal cord to an expressway, where an accident there would result in a traffic jam, he said the treatment is assumed to work by helping to widen the road a bit to let more cars go through.
'The brain signals can then easily go through the area, because you have now managed to augment the signalling around the area,' he said.
The loaned device used in AH's trials is the ARC-EX system from ONWARD Medical. The firm's global clinical trial for the therapy, the results of which were published in the Nature Medicine journal in 2024, had found that 72 per cent of the 60 study participants who completed the trial demonstrated improvement in both strength and function.
It came in late 2024, nearly three years after Dr Chandran and Adjunct Associate Professor Effie Chew, AH's head of the division of rehabilitation medicine, made a field trip in 2022 to the Reade rehabilitation hospital in Amsterdam – one of the sites in the trial done across the United States, Europe, and Canada – to learn about this new device and observe its use on patients.
The loaned device used in Alexandra Hospital's trials is the ARC-EX system from ONWARD Medical.
ST PHOTO: SHINTARO TAY
In a statement released through AH, ONWARD Medical CEO Dave Marver said that it was excited to support the study, the first of its kind in Singapore and Asia, as they work on expanding access to their technologies globally.
'The preliminary results reported by Dr Gobinathan Chandran and his team validate what we have seen in other regions – that ARC-EX Therapy, when combined with physical therapy, can enable meaningful improvements for people living with spinal cord injuries,' he said.
Meanwhile, AH has also just received ethics approval to study the use of non-invasive electrode stimulation in 16 SCI patients with upper-limb functional impairments.
Elsewhere in Singapore, there is another trial studying the use of surgically-implanted electrode near the spinal cord to restore motion for patients with complete spinal cord injuries. The Restores (restoration of rehabilitative function with epidural spinal stimulation) clinical trial is conducted by NNI, TTSH and A*Star.
It has completed the first phase, with three patients, and is moving into the second phase, with 15 patients, later this year.
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