## 3 Treatments for Spinal Cord Injury
### Transcranial Magnetic Stimulation (TMS)
This tailored approach aimed to maximise therapeutic outcomes by aligning stimulation intensity with each patient's unique neurophysiological response, potentially aiding mobility and recovery in those with spinal cord injuries. Although this study showed a possibility of aiding with mobility, it does not show a significant enough success rate for long-term use. The patient, in this case, is also dependent on receiving multiple sessions  
Figure 6: The structure of a transcranial magnetic stimulation device. This example shows how the magnetic signals from the copper coils in the device impact the local neurons in the brain and travel through the spinal cord to illustrate various actions [37]. of treatment a month, which may interfere with the patient's quality of life. Overall, this method is not considered a long-term solution for spinal cord injury [39]. Moreover, [PERSON] et al. at King's College London were able to study the current evidence, challenges, and possible future directions for the use of negative transcranial magnetic stimulation (nTMS) in spinal cord injury [40]. This study evaluated nine clinical studies involving the use of TMS for rehabilitation in spinal cord injury. Each study had 11-115 participants and focused on incomplete and traumatic spinal cord injury across 4-8 weeks. Various TMS protocols were used in each study, including PAS, intermittent theta bursts (iTBS), and different combinations of trans-spinal direct current stimulation (ts-DCS). Most of the studies analysed showed an improvement in the lower extremity motor score (LEMS), muscle activation patterns, and neuroplasticity. Though there was improvement, the study emphasised the need for standardised protocols to integrate into clinical practice as various stimulation parameters and treatment durations were assessed [40]. This research provides a valuable insight into nTMS therapy for SCI rehabilitation, yet further research is needed to refine treatment protocols and patient selection criteria. [PERSON] et al. further assessed the use of TMS in a pilot randomised clinical trial to investigate the efficacy of combining repetitive TMS (rTMS) with body weight-supported treadmill training (BWSTT) to enhance walking function in individuals with chronic incomplete spinal cord injury (iSCI) [41]. The use of rTMS was discussed as a non-invasive brain stimulation device, which resulted in the modulation of cortical excitability [42]. On the other hand, BWSTT was used, as it allows for the recurrence of a complete gait cycle and initiation of the spinal central pattern generator [43]. The study evaluated the neuromuscular activation, functional independence, and gait recovery over 4 weeks. The rTMS device used was a non-invasive electromagnetic coil that was placed over the primary motor cortex to deliver pulsed magnetic stimulation. There were 15 individuals with chronic iSCI, divided into the real rTMS and BWSTT and the mock rTMS and BWSTT groups. The real group received a 10 Hz stimulation with 1800 pulses per session, while the mock group received placebo stimulation. The BWSTT protocol included 15-20 min of moderate-intensity treadmill training per session with the assistance of a reduced weight-bearing harness. Results of the study illustrated that after twelve sessions, the real rTMS group showed significantly more positive results than the mock rTMS group. The motor function recovery was improved through enhanced neuromuscular activity for the real rTMS group, compared to the mock rTMS group [41]. Limitations to this include a small sample size of only 15 patients and the short experimental duration of four weeks, which limit generalisability and do not assess the long-term effects. Furthermore, the device used was not an implantable device, which means the effects of the device would be temporary and dependent on battery charging, resulting in a period when the patient reverts to the original SCI state.