Objective Biomarker Development for Parameter Optimization in Neuromodulation Using High-Density EMG Temporal and...

Transcutaneous spinal cord stimulation (tSCS) is a promising neuromodulation approach for motor recovery after spinal cord injury (SCI), yet clinical programming remains largely dependent on subjective parameter selection. This study evaluated high-density surface EMG (HD-sEMG)-derived spatial and temporal features as objective biomarkers for tSCS optimization in three adults with chronic cervical SCI. A 64-channel electrode array recorded stimulation-evoked responses across five cervical stimulation levels, four pulse widths, and graded amplitudes. Features describing activation magnitude, spatial distribution, cluster morphology, and temporal dynamics were extracted from epoch-based activation maps. Of the three enrolled participants, two demonstrated measurable stimulation-evoked responses and contributed to the paired-pulse analyses, whereas pulse-width analyses were limited to a single responsive muscle (left flexor carpi) in one participant. Paired-pulse analysis identified root mean square (RMS) as the most discriminative feature, revealing nonlinear, muscle- and level-specific dose-response relationships in which maximal suppression often occurred at intermediate rather than maximal amplitudes. Increasing pulse width expanded the spatial extent of recruitment (active area: p = 0.006; convex hull area: p = 0.004) without altering response timing. Polarity reversal analysis demonstrated stable innervation zone localization across stimulation levels and amplitudes. These findings establish a spatially resolved HD-sEMG framework that may support individualized tSCS parameter selection in SCI.