SCIMS Project 1: Enhancing Corticospinal Activation for Improved Walking Function
Phase: NA
Conditions: Spinal Cord Injuries
Sponsor: Shepherd Center, Atlanta GA

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SCIMS PROJECT 1: ENHANCING CORTICOSPINAL ACTIVATION FOR IMPROVED WALKING 
FUNCTION. 
 
 
ClinicalTrials.gov#: NCT03237234 
 
 
 
 
Principal Investigator 
Edelle C Field-Fote, PhD 
2020 Peachtree Road, NW 
404-603-4274 
edee_field-fote@shepherd.org 
 
Study Coordinator: 
Nicholas H. Evans, MHS 
 
 
 
 
 
Document History 
Original Protocol: Version 2.0 11/15/2016 
 
 
 
 
 
 
This document contains confidential and proprietary information.  Therefore, this document should be 
maintained in a secure location and should not be copied or made available for review by any unauthorized 
personnel 
 
 

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Statement of Compliance 
 
 
This study will be carried out in accordance with Good Clinical Practice (GCP) as required by the United States 
Code of Federal Regulations (CFR) applicable to clinical studies (45 CFR Part 46, 21 CFR Part 50, 21 CFR Part 
56, and 21 CFR Part 312). 
 
 
 
______________________________________________ 
__________________ 
Principal Investigator Signature  
 
  
 
  Date  
  
 
 
______________________________________________  
Principal Investigator Printed Name 
 
 
 
 
 
 
 
 

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Table of Contents 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
1. Introduction 
 
2. Study Objectives and Endpoints 
 
3. Study Design 
 
4. Adverse Events 
 
5. Data Management 
 
6. Statistical Considerations 
 
7. Ethical, Regulatory, and Administrative Considerations 
 
8. Study Medication/Device/Intervention 
 
9. References 
 
10. Appendices 
 
 
 

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1.0   Introduction 
Spinal cord injury (SCI) occurs suddenly and unexpectedly to an estimated 12,500 people each year, and over 
275,000 people are thought to be living with SCI in the United States alone.[1] Restoration of walking is cited as 
a priority among persons with SCI, regardless of severity, chronicity, or age at injury.[2] To address this priority, 
numerous approaches have been implemented to restore locomotor function either through physical training [3] 
and/or through the use of rehabilitation technology.[4] High-tech approaches to improving function after SCI are 
exciting and receive much media attention; however, a recent systematic review found that, of the many 
interventions aimed at improving motor function, the strongest evidence supports those strategies that include a 
physical training component.[5] Despite the potential benefits, current rehabilitation strategies aimed at the 
restoration of walking function often require access to intensive training programs conducted over extended 
periods of time and to facilities and equipment that may not be available in the homes or communities in which 
individuals with SCI live. Therefore, it would seem that the keys to optimizing long-term recovery of function are 
to identify those therapies that extract the greatest improvement over the shortest period of time and to identify 
training approaches that are readily accessible in the home environment. These considerations, along with three 
important findings in the research, form the basis of this project.  
 
First, evidence from a large multi-million dollar locomotor training study involving persons with stroke found that 
a well-designed exercise program can be as effective for improving walking function as an intensive locomotor 
training program.[6] Second, a single session of moderate-intensity exercise has been found to promote motor 
skill acquisition, presumably through neurotrophic mechanisms, and to reduce spasticity.[7-9] In persons with 
SCI, 10 minutes of moderate-intensity activity (54% of maximal heart rate) was associated with a 1.5-fold 
increase in serum levels of neurotrophic factor.[7] Studies investigating locomotor training in persons with SCI 
[10] and in spinal rats suggests that exercise can restore the endogenous inhibition that is lost after SCI [11], 
which may affect the extent and severity of spasticity.[9] Third, supraspinal centers are known to be involved in 
locomotion, yet studies aimed at improving walking function have focused almost exclusively on activation of 
spinal circuits.[12] In rodent models with SCI, evidence indicates that recovery of locomotor function depends 
largely on activation of spared supraspinal pathways [13] and that there is an increased amplitude of lower limb 
motor evoked potentials following intensive locomotor training in humans with SCI.[14] These studies suggest a 
relationship between the strength of corticospinal drive and walking function. Therefore, it seems plausible that 
walking function can be improved by increasing the effectiveness and activation of spared descending pathways.  
 
A preponderance of the evidence suggests that corticospinal drive is increased by combining moderately intense 
motor training with stimulation of supraspinal centers. This notion is supported by research demonstrating that 
intensive motor training aimed at increasing corticospinal drive improves muscle activation and walking 
function.[15] Furthermore, non-invasive brain stimulation has been shown to improve lower extremity strength, 
lower-limb control, gait, and balance.[16-19] Cortical stimulation with repetitive transcranial magnetic 
stimulation (rTMS) has been associated with improved walking function in persons with SCI [20], although this 
form of stimulation has inherent drawbacks that limit its use in clinical settings. An alternative to rTMS is 
transcranial direct current stimulation (tDCS), which is a low-risk, non-invasive brain stimulation technique 
involving low-intensity currents delivered to the motor cortex and aimed at modulating cortical excitability. tDCS 
is affordable and lacks many of the drawbacks associated with rTMS, making it a more clinically accessible 
technology. Emerging studies in persons with stroke have combined tDCS with moderately intense motor training 
and have demonstrated increased dorsiflexor control,[16] quadriceps strength,[17, 18] and balance.[17] tDCS may 
also have the capacity to modulate excitability of spinal networks and to decrease spasticity.[21, 22]  
 
 
Based on the evidence described above, we put forward two primary goals of the proposed project: 1) determine 
whether a moderate-intensity training program designed to increase control of gait-related movements can 
improve functional and neurophysiologic measures, and 2) determine whether training-related responses are 
larger when training is augmented with cortical stimulation to increase supraspinal drive.  

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2.0   
Study Aims and Hypotheses: 
 
2.1 
Aim 1. Quantify effects of moderate-intensity motor training alone (MT-only group) and 
moderate-intensity motor training + tDCS (MT+tDCS group) on walking function and balance. 
We hypothesize that training will be associated with improvements in locomotor function 
(walking speed and step height), balance (Berg Balance Test), and leg muscle strength 
(quadriceps and plantarflexor muscles). We also hypothesize that gains in the MT+tDCS group 
will be larger than those of the MT-only group. 
 
 
2.2 
Aim 2. Quantify effects of moderate-intensity motor training alone (MT-only group) and 
moderate-intensity motor training + tDCS (MT+tDCS group) on leg muscle strength and 
spasticity. We hypothesize that training will be associated with We also hypothesize that gains 
with MT+tDCS group will be larger than those with MT-only. 
 
3.0 
Study Design 
 
3.1 
Study Sample: 
Thirty-five (35) participants with chronic (≥12 months post injury), motor-incomplete SCI (i.e. 
American Spinal Injury Association Impairment Scale (AIS) C or D)[23] will be recruited for the 
study. Upon enrollment, participants will be expected to have some, but limited, walking ability 
(detailed inclusion/exclusion criteria listed below). 
 
3.1.1 
Inclusion Criteria: 
The research participants must meet all of the following criteria to be eligible for the 
study: 
• 
Ability and willingness to consent and Authorization for use of PHI; 
• 
Chronic SCI (≥12 months post-injury) at or above the neurological level of T10; 
• 
Age 18-65; 
• 
Able to stand (with or without the aid of an assistive device) for at least 5 minutes; 
• 
Able to advance each leg independently for at least 3 steps. (For over ground 
locomotion, assistive devices including ankle-foot orthoses [unilateral or bilateral], 
knee-ankle-foot orthoses [unilateral only], walkers, crutches, or canes may be used); 
• 
Able to rise from sit to stand requiring no more than moderate assistance from one 
person. 
 
3.1.2 
Exclusion Criteria: 
The presence of any one of the following criteria would lead to exclusion: 
• 
Inability or unwillingness to consent and Authorization for use of PHI; 
• 
Progressive, or potentially progressive, spinal lesions including degenerative, or 
progressive vascular disorders of the spine and/or spinal cord; 
• 
Injuries below the neurological spinal level T10; 
• 
History of cardiovascular irregularities; 
• 
Altered cognitive status; 
• 
Presence of orthopedic pathology that would adversely influence participation in the 
protocol (e.g. knee or hip flexion contractures of greater than 10 degrees); 
• 
Implanted metallic objects in the cranium (e.g. aneurysm clips); 
• 
History of seizures; 
 

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NOTE: The use of prescription medications, including a baclofen pump for control of 
spasticity, will not be a basis for exclusion so long as the dosage has been stable for at 
least 90 days. 
 
3.2 
Procedures: 
 
3.2.1 
Research Design: 
We propose a double-blinded, randomized, cross-over intervention study consisting of a 
moderate-intensity motor training circuit of gait-related upright motor control activities. We will 
also assess whether the addition of tDCS augments the training-related gains. Effects of training 
(and tDCS) on walking function, balance, strength, and spasticity will be assessed to determine 
whether there is preliminary evidence of efficacy of this approach. 
 
Stratified randomization: To ensure equivalence of baseline data between groups, stratified 
randomization will be used. We have shown that persons with SCI who are ambulatory may be 
classified into one of two groups, with “less impaired” participants having lower limb motor 
scores of >15 for one leg and ≥10 for the other leg; participants not meeting this criteria are 
classified as “more impaired”.[3] To ensure equivalent distribution of more- and less-impaired 
participants between groups, individuals will be stratified into one of these two strata based on the 
above criteria, with randomization to groups within each stratum. 
 
Schedule of Events:  
Individuals will be asked to participate in the study over two, 5 consecutive day periods. 
Following completion of the fifth day, participants will be asked to take 2 weeks off before 
returning to the lab to repeat the intervention schedule but in the opposite group in which they 
originally participated (i.e. MT-only to MT+tDCS; MT+tDCS to MT-only). A detailed schedule 
of events including testing and intervention timing is provided in Figure 1. 
 
Figure 1. Timing of intervention and outcome measures.  
 

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3.2.2 
Interventions: 
Motor training (MT): The muscles targeted for motor training have been selected based on 
studies in persons with SCI that have identified the muscle groups that best predict walking 
ability.[24-27] Motor training (see Figure 2) will consist of a circuit of activities that, with the 
exception of the toe tap task, will be performed while standing to promote upright control (the 
toe-tapping activity will be performed in sitting as, in our experience, many people with SCI are 
unable to perform this activity when the hip and knee are in an extended position). Participants 
will perform each of the 6 different training activities for one minute each (with modifications as 
necessary to allow successful execution), alternating between legs, until 4 cycles of the circuit 
have been completed (approximately 25 minutes total). This exercise duration was selected based 
on prior studies showing that in persons with SCI, 10 minutes of moderate intensity activity (54% 
age-predicted maximum heart rate) increased serum levels of neurotrophic factor.[7] 
Furthermore, a single 15-minute session of gait and balance training in combination with tDCS 
improved walking speed and balance in persons with motor dysfunction.[19]  
 
 
 
Figure 2. Moderate-intensity motor training activities. Motor training activities will be performed 
at an intensity intended to attain a target exercise intensity of 40–59% of heart rate reserve (HRR) 
for 5 of 6 activities; toe tapping (the exception) performed in sitting, will provide the opportunity 
for scheduled rest. During MT, all participants will wear a heart rate monitor chest strap synced to 
a wrist watch to ensure that the optimal HR range is achieved. HRR will be calculated from 
resting and peak heart rate measures obtained during baseline testing via administration of a 
graded-exercise test (GXT) (Appendix H). The GXT will consist of a maximal continuous upper-
body exercise test performed on an arm crank cycle ergometer (Monark 881E Arm Ergometer). 
Cardiorespiratory data will be collected continuously from inspired and expired gases using a 
cardiometabolic testing device (COSMED Quark CPET, Chicago, IL). Heart rate will be assessed 
simultaneously using an integrated heart rate monitor (Polar WearLink® + transmitter, Polar 
Electro Inc., NY). Maximal GXT termination criteria and test procedures will be followed as per 
standards set forth by the American College of Sports Medicine.  
 
Non-invasive brain stimulation (tDCS): The tDCS electrode placement is based on procedures 
shown to improve gait and balance in a single session when used in combination with gait 
training activities.[19] tDCS electrodes can simultaneously activate the bilateral leg motor areas 
when placed at the midline of the scalp slightly anterior to the vertex (anode) and at the inion 
(cathode), with a current intensity of 2mA. The tDCS device is lightweight, and can be worn in a 
backpack during the MT activities. As reported previously [19], participants in the MT-only 
group will receive sham tDCS to maintain analogous study procedures. Appendix A provides a 
detailed description of tDCS set-up and implementation. 
 
 

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3.2.3 
Outcome Measures: 
Outcome measures will be assessed at several time-points throughout the study (see Figure 1). 
We emphasize that both moderate-intensity motor training and tDCS have been reported to have 
significant single-session effects. Our testing schedule will allow us to capture both the 
immediate effects (also referred to as “online effects” [28]), and persistent effects (or “offline 
effects” [28]). Immediate Effects will be assessed within each intervention day, prior to and 
following the intervention. Persistent Effects will be assessed by comparing baseline measures to 
measures obtained following the 3rd intervention day. To minimize participant burden and 
because single-session effects may not last for prolonged periods, only a subset of outcome 
measures will be collected before and after each training session. Table 1 outlines the timing of 
specific outcome measures to be performed in order to determine the Immediate and Persistent 
Effects. 
 
 
 
 
 
 
 
Walking Function: Walking speed will be the primary outcome measure for walking function, as 
speed has been the standard measure used in the literature and will allow us to assess outcomes 
relative to other published studies. As in our prior studies, functional walking capacity will be 
measured based on 2-minute walk test distance.[3] The use of the 2-minute rather than the 6-
minute walk test allows us to include individuals whose impairments result in inability to walk 
for 6 minutes. Kinematic data related to walking performance will be obtained using an 
accelerometer-based motion capture system (Xsens MVN Biomech Awinda, Xsens, Enschede, 
Netherlands) as the participant walks along a 15-meter path, using only the passive assistive 
devices they typically use (e.g., lower limb orthotics, walker, forearm crutches). Secondarily, we 
will assess gait quality as reflected by step height, step length, and step symmetry. Appendix B 
provides a detailed description of walking function test set-up and implementation. 
 
Balance: Balance will be measured using the Berg Balance Scale, which has been found to be 
valid for use in persons with SCI. Appendix C provides a detailed description of balance test set-
up and implementation. 
 
Fall Efficacy Scale-International (FES-I) 
The fear of falling may be a major concern for persons with mobility impairments and may limit 
one’s confidence or ability to perform activities of daily living [29, 30]. Fear of falling may also 
limit an individual’s performance of specific overground motor tasks irrespective of functional 
ability to perform that task [31]. Therefore, the fear of falling will be an important factor to 
consider relative to the mobility interventions employed in the present study. The FES-I [32] will 
Table 1. Outcome measures timing. 
 
Baseline 
Measures 
Immediate  
Effects 
Persistent 
Effects 
Walking Speed 
⚫ 
⚫ 
⚫ 
Walking Distance 
⚫ 
 
⚫ 
Balance 
⚫ 
 
⚫ 
Fear of Falling 
⚫ 
 
⚫ 
Ankle dorsiflex strength 
⚫ 
⚫ 
⚫ 
Knee extensor strength 
⚫ 
 
⚫ 
Functional leg strength 
⚫ 
 
⚫ 
Spasticity 
⚫ 
⚫ 
⚫ 
BDNF 
⚫ 
⚫ 
⚫ 

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be used to assess baseline and post-intervention perception of fear of falling. Appendix D 
provides a description of the FES-I test implementation. 
 
Isometric muscle strength Ankle dorsiflexion (tibialis anterior) strength will be measured with 
the participant seated, with the test foot strapped onto a foot plate that is attached to a force 
transducer. An ankle dorsiflexion test was selected based on evidence indicating that the tibialis 
anterior is under the greatest corticospinal control.[33, 34] Maximum dorsiflexion torque will be 
calculated based on the maximum value obtained during three attempts. A similar approach will 
be used to assess knee extensor (quadriceps) strength, as prior studies have shown that a single 
session of tDCS improves quadriceps strength in persons with stroke.[18] Appendix E provides a 
detailed description of isometric strength test set-up and implementation. 
 
Functional lower extremity strength: The Five Times Sit-to-Stand test has been validated for use 
in persons with motor-incomplete SCI and shown to be correlated with walking ability. 
Consistent with our previous publications, we will implement the Modified Five-Times Sit-to-
Stand test as a measure of functional lower extremity strength.[35] In the modified version of this 
test, the participant will be seated on an adjustable mat table with height adjusted to 80% of lower 
extremity length (as measured in the standing position with shoes on from the greater trochanter 
to the floor). The participant’s feet will be positioned shoulder width apart (as measured from the 
center of each foot equal to the distance between the acromion processes). The feet will be 
positioned either forward or backward until a position is reached in which the lower leg is 
perpendicular to the floor. Participants will be instructed to, “stand up, balance, and sit back 
down.” The participant will begin in the seated position with back unsupported and will be given 
a “3-2-1-Go” command to initiate standing. Repetitions in which the participant fails to achieve 
full upright standing will not be counted (i.e., a standing attempt will not be counted if only a 
partial stand is completed). Participants will also be verbally encouraged to exert equal effort 
between legs when standing. The total time required to complete 5 repetitions of standing up and 
sitting down (without using the upper extremities for assistance) will be recorded. Participants 
unable to complete the task without upper extremity support will be given a maximum time of 
180 seconds (3minutes) so that pre/post differences can be calculated.  If participants are not able 
to obtain this position or cannot stand without modifying this position, they will also be given a 
score of 180 seconds.  Appendix F provides a detailed description of functional lower extremity 
strength test set-up and implementation. 
 
Spasticity: Both motor training [9, 11, 15] and the use of tDCS [21, 22] have been associated with 
decreased spasticity. We will use the Spinal Cord Assessment Tool for Spastic Reflexes to assess 
the impact of MT-only and MT+tDCS on spasticity. This measure is well correlated with 
electrophysiological measures of spasticity and is better correlated with self-reported measures of 
spasm frequency than the Ashworth test.[36] Appendix G provides a detailed description of 
spasticity test set-up and implementation.
 
Serum Brain-Derived Neurotrophic Factor (BDNF): Serum concentrations of BDNF 
will be measured in venous blood. Venous blood samples (10 mL) will be drawn by a 
Shepherd Center phlebotomist and stored in pre-chilled serum venipuncture tubes. 
Samples will be allowed to clot for 1 hour at room temperature and 1 hour at 4°C. Serum 
will be separated by centrifugation (1000 x g for 15 min) and stored in Eppendorf tubes at 
-70°C until analysis. At least once per month, blood samples will be transported by the 
study coordinator by car to the Georgia Institute of Technology, Department of Applied 
Physiology for analyses. Blood serum samples will be analyzed for BDNF by enzyme-
linked immunosorbent assay (ELISA) using Mature Rapid ELISA kits from Biosensis 
(Cat #: BEK-2211-1P/2P, Biosensis Pty Ltd., SA, Australia) with a detection range from 

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7.8 pg/ml to 500 pg/ml. Preparation of mature BDNF standard and other assay 
procedures will be followed according to manufacturer’s specifications (Appendix I). A 
total of 4 blood samples will be collected for each participant, and serum BDNF 
concentrations (ng/ml) will be compared across the following time points: baseline (Day 
1), pre-exercise (Day 2), post-exercise (Day 2), and persistent test (Day 5).  
 
 
3.2.4 
Laboratories: 
The following laboratory will be used as the primary site of this study:   
Hulse Spinal Cord Injury Laboratory 
Shepherd Center 
 
 
 
2020 Peachtree Road, NW 
 
 
 
Atlanta, GA 30309 
 
The following laboratory will be used for blood sample analyses: 
 
 
 
Ryanodine Receptor Laboratory 
 
 
 
Georgia Institute of Technology 
 
 
 
555 14th Street NW 
 
 
 
Atlanta, GA 30332 
 
4.0 
Adverse Events 
 
4.1 
Definitions 
 
Adverse Event (AE) - any untoward physical or psychological occurrence or 
undesirable and unintended effect for a participant that may present itself during 
interventions and interactions used in the research or the collection of identifiable 
private information under the research, regardless of whether there may or may 
not be a relationship with the research intervention.   
 
Unanticipated Adverse Event – any adverse event, the specificity, frequency or 
severity of which is not consistent with either: 
 
• 
The known or foreseeable risk of adverse events associated with the 
procedures involved in the research that are described in the protocol related-
documents, such as the IRB-approved research protocol, any applicable 
investigator brochure, and the current IRB-approved informed consent 
document, and other relevant sources of information, such as product 
labeling and package inserts; or 
• 
The expected natural progression of any underlying disease or condition of 
the participant(s) experiencing the adverse event 
 
Anticipated Adverse Event: - an adverse event that is not an unanticipated 
adverse event.  The following adverse events are considered as anticipated: 
 
• 
Although tDCS has been shown to have minimal risk compared to other 
forms of non-invasive brain stimulation (i.e. TMS)[37], it has been 
associated with temporary itching/tingling at stimulation onset/offset and, 
occasionally, headaches. tDCS is associated with skin irritation and 
superficial blistering; however, the occurrence of these side effects is rare 
and, when they do occur, temporary. 

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• 
Motor training activities consist of dynamic exercises involving concentric 
and eccentric muscle contractions. This type of training may increase the 
mechanical forces placed on muscles and connective tissues of the lower 
extremities beyond that which participants may be accustomed. As a result, 
participants may experience signs and symptoms of delayed onset muscle 
soreness (DOMS) within the first 24-48 hours of training, the severity of 
which should lessen over the course of the training period. Participants’ 
perceived severity of DOMS will be assessed prior to each session using a 1-
10 verbal pain scale. Ratings of 8 or higher will result in a cancellation of 
that session. Participants will be instructed to take the day off, rest, and 
return for the next scheduled session.  Participants will be assessed for 
pain/swelling of the lower limbs and joints prior to each training session and 
any abnormalities will be referred appropriately for medical management. 
• 
There may be risks associated with blood tests. Taking blood may 
cause discomfort, bruising and, very rarely, infection where the needle 
goes into the skin. Participants may also experience dizziness, nausea, 
or fainting during blood draws. Participants will be instructed to 
inform the attending phlebotomist drawing the blood or other member 
of the study team if they are not feeling well while blood is being 
taken or at any time after blood has been taken. 
 
Unanticipated Adverse Device Effect – any serious adverse effect on health or 
safety or any life-threatening problem or death caused by, or associated with, a 
device, if that effect, problem, or death was to previously identified in nature, 
severity, or degree of incidence in the investigational plan or application 
(including a supplementary plan or application), or any other unanticipated 
serious problem associated with a device that relates to the rights, safety, or 
welfare of participants. 
 
Related or possibly related to the research: - an event is related to the research if, 
in the opinion of the Principal Investigator, it could not have been produced by 
the participant’s clinical condition or environment, follows a known pattern of 
response to intervention, disappears or decreases with reduction in dose or 
cessation of intervention and/or recurs with re-exposure and/or it was more likely 
than not to be the result of the collection/disclosure of identifiable private 
information in the research and/or the interventions used in the research. 
 
Unrelated to the research: - an adverse event is unrelated to the research if, in the 
opinion of the Principal Investigator, the adverse event is clearly due to 
extraneous causes (e.g., underlying disease or environment) does not follow a 
known pattern of response to intervention, and/or does not reappear or worsen 
with re-introduction of the intervention. 
 
Serious Adverse Event:  an event is considered serious if it results in death, is 
life-threatening, requires hospitalization or prolongation of hospitalization, 
causes persistent or significant disability or incapacity, is a birth defect or 
congenital malformation, represents, in the Principal Investigator’s judgment, 
other significant hazards or potentially serious harm to research participants or 
others, or any other event as described in the research process. 
 

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4.2 
Reporting 
Each participant will be observed and queried in a nonspecific fashion at each 
contact during the study for any new or continuing symptoms since the last 
contact. All adverse events will be reported on the appropriate electronic Case 
Report Form (eCRF).  Details will include the type of event, date of onset, 
duration, intensity, causality relationship to the study drug(s) (if applicable), and 
outcome.  Wherever possible, a diagnosis rather than symptom(s) will be 
reported. 
 
If an adverse event should occur, every attempt will be made to obtain as much 
information as possible about event evaluation and outcome.  Documents of this 
follow-up will be maintained with the patient’s study records.   
 
If a serious adverse event occurs, the treatment will be interrupted or 
discontinued at the physician investigator's discretion.   
 
All protocol deviations will be reported to the investigator and the Institutional 
Review Board (IRB).  
 
All adverse events will be reported to the IRB.  All serious adverse events will be 
reported immediately to the IRB and the FDA (if applicable). 
 
Endpoints will be adjudicated by the Principal Investigator.  A written report 
detailing the endpoint adjudication will be provided by the Principal Investigator. 
 
 
4.3 
Potential Side Effects 
Potential side effects have been listed under Anticipated Adverse Events in 
Section 4.1.  
 
4.4 
Safety 
This study will be conducted in accordance with the principles of Good Clinical 
Practice as outlined in the Declaration of Helsinki and the International 
Conference on Harmonization. 
 
All efforts will take place to ensure patient safety. Each participant will be 
monitored for safety throughout the trial utilizing clinical evaluations and 
laboratory markers.   
 
Laboratory markers and/or clinical evaluations that are out of normal range will 
be recorded as adverse events and reviewed with the investigator.   
 
SAE’s noted to be study drug/device/research intervention related will be 
reported as appropriate and [study drug/device/ intervention is to be discontinued 
per the decision of the investigator].   
 
All participants will be triaged to the appropriate medical care based on 
investigators decision upon review of abnormal events.   
. 
5.0    
Data Management  

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Following completion of the consenting process (including informed consent and 
Authorization for Use/Disclosure of PHI) and it has been determined that the participant 
meets all of the inclusion and none of the exclusion criteria, enrollment will occur and 
data collection will commence. 
 
5.1 
Case Report Forms 
Hospital, office, and research records for any admission or visit (including 
admission notes, discharge notes, operative reports, test results, and lab reports) 
are considered source documentation and will be collected and reviewed to 
confirm clinical events and may be utilized for data analysis. Data will be 
collected on all participants via an eCRF.  The CRF will contain no participant 
names.  The participant code field will be a patient study number, numbered 
sequentially as entered into the electronic database.  A separate master code list 
will be constructed by the investigator/study coordinator that will list the patient 
name with the designated participant code.  This list will be maintained in a 
password protected file to which only investigators involved in the project will 
have access. 
 
Upon completion of data collection, an eCRF will be printed for the participant, 
signed by a Principal Investigator, and filed in the participant’s research chart. 
 
5.2   
Database 
Data will be collected and maintained in electronic form by Mr. Brandon Poe. 
Data entry, development of the primary database, and all statistical analyses will 
be the responsibility of Mr. Nicholas Evans. The electronic database will be 
backed up per institutional guidelines. 
  
5.3   
External Documentation: 
During administration of the patient questionnaire, if it is identified that a 
participant sought treatment from a source outside of the Hulse Spinal Cord 
Injury Laboratory after enrollment into the protocol, additional data will be 
obtained from external physician offices or hospitals to document and verify 
events.  All data will be entered onto the follow-up eCRF. 
 
5.4   
Quality Control 
Mr. Brandon Poe will fulfill the responsibilities identified in their standard 
operating procedures.  These responsibilities include collecting and tracking data 
forms and instituting quality control measures for data entry verification and 
study compliance. He will request further documentation such as physician 
and/or procedure notes when complications are observed and reported.  Mr. Poe 
will also be responsible for auditing the database and confirming the overall 
integrity of the data. He will ensure that all information pertaining to significant 
new developments and unanticipated adverse events are provided to the 
appropriate regulatory authorities, the Investigators, and to the IRB. 
 
Monitoring of the study will be conducted at regular intervals in order to monitor 
study conduct and maintain Good Clinical Research Practice.  These inspections 
are conducted in order to verify adherence to the protocol and the completeness 
and accuracy of the data being entered into the eCRF. 
 
6.0 
Statistical Considerations 

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The study protocol must provide the research methodology with sufficient detail to answer the following 
questions:  
1) Is the sample size and nature appropriate for the goals of the study?  
2) For placebo-controlled studies, is there adequate justification for a placebo arm; is the duration of the 
intervention limited to that which is minimally necessary; is there adequate monitoring of participants 
receiving placebo?  
3) Are there defined endpoints for discontinuing experimental treatment in the event of a worsening 
condition? 
4) Is the proposed research design and statistical treatment of data appropriate and sufficient?  
5) Does the proposed research carry enough likelihood of yielding valid information to warrant the 
participation of Shepherd Center patients? 
 
6.1   
Statistical Assumptions 
All data will be managed using Microsoft Excel and analyzed using SPSS. 
Descriptive statistics, including means, standard deviations and 95% confidence 
intervals of the pre-post change for each condition will calculated for all 
measures. The baseline characteristics of the participants assigned to the 2 
intervention groups will be compared using ANOVA and Chi-square analysis. 
The change from Baseline test (day 1) to Persistence test (day 5) for the two 
intervention groups will be compared using repeated measures ANOVA followed 
by pair-wise contrasts between the two groups. Pair-wise t-tests with Bonferoni 
correction for multiple comparisons will be used to evaluate within-day change 
for each of the 3 intervention days. We will identify the effect size and 95% 
confidence interval associated with effects to identify the outcome measures that 
are most sensitive to change following intervention with MT-only and 
MT+tDCS. We will also assess variables associated with responsiveness to 
intervention, using logistic linear regression to identify the variables that are most 
strongly associated with change in our primary outcome measure of walking 
function. Where significant pre/post differences exist among the primary 
outcome measures and blood serum concentrations of BDNF, Pearson correlation 
coefficients will be calculated to determine the strength of any relationship that 
might exist between measures of walking function and changes in BDNF 
concentration. 
 
6.2 
Sample Size 
While our primary interest is in assessing the value of an intensive motor training 
program for improving measures of function, we are also interested in assessing 
between-groups differences in those who do versus do not receive tDCS to 
augment training. Our primary outcome measures are related to walking function. 
Sample size calculation is based on our published study from participants trained 
with intensive motor training alone, wherein the improvement in walking speed 
had an effect size of 0.69.[15] Based on this effect size, in order to identify pre-
post differences due to training using the full study sample, a sample size of 15 
participants is required to obtain a power of 0.8 with α = 0.05. However, since we 
are also interested in between-group differences between the MT+tDCS and MT-
only groups, if we assume an additive or larger effect of the tDCS, it will be 
necessary to double the sample size to 30, with 15 participants per group to 
identify significant between-groups differences at the same power and alpha 
levels. To accommodate an anticipated 15% attrition rate we will enroll 35 
participants. 
 

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6.3 
Project Implementation Plan 
Table 3 provides a summary of the project implementation plan. 
 
Table 3. Project Implementation Plan 
Timeline 
(Mths) 
Investigator(s) 
Major Task 1: Management Activities 
Prepare regulatory documents and research protocol for the study. Modify the study according to 
Shepherd Center RRC recommendations. 
Refine eligibility criteria, exclusion criteria, screening protocol 
1-3 
EFF/NE 
Finalize consent form & human participants protocol 
1-3 
EFF/NE 
Submit RRC protocol for review 
1-3 
EFF/NE 
Submit protocol for IRB approval 
1-3 
EFF/NE 
Submit amendments, adverse events, and protocol deviations as 
needed 
As 
Needed 
NE 
Annual IRB report for continuing review 
Annually 
EFF/NE 
Major Task 2: Coordination Activities 
Coordinate training of project staff 
1-6 
EFF/NE 
Coordinate supervision and fidelity checks as needed for 
attrition 
Quarterly 
EFF 
Major Task 3: Research Activities  
Coordinate all study steps, data collection and database 
requirements  
3-6 
EFF/NE/BP 
Finalize assessment measurements 
3-6 
EFF/NE 
Begin participant recruitment 
6 
NE 
Perform participant baseline evaluations/assessments 
6-42 
NE 
Participants complete assigned intervention and “immediate 
effects” measured 
6-42 
NE 
Participants complete “persistent effect” measurements 
6-42 
NE 
Major Task 4: Data Analysis Activities 
Monitor data collection procedures and data quality 
6-42 
EFF/NE/BP 
Perform all analyses according to specifications, share output 
and findings with study investigators 
42 
EFF/NE 
Major Task 5: Dissemination Activities 
Prepare manuscripts, abstracts, and presentations 
43-48 
EFF/NE 
Submit manuscripts, abstracts, and report findings at relevant 
national/international conferences 
43-48 
EFF/NE 
Abbreviations: IRB (Institutional Review Board);  
EFF (Edelle Field-Fote); Nicholas Evans (NE);  
Brandon Poe (BP); 
 
 
6.4 
Estimated Duration of the Study 
It is estimated that this study will take approximately 48 months to complete.  
Accrual will require approximately 42 months for completion. Table 4 provides 
an estimated timeline of events for the study. 
 
Table 4. Estimated timeline of study events. 
Activity 
Timeline (Months) 
Enrollment 
6-42 
Treatment and Data Acquisition 
3-42 
Analysis of Primary Outcomes 
42-48 
Safety Monitoring 
1-48 

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7.0 
Ethical, Regulatory, and Administrative Considerations 
 
7.1 
Informed Consent 
The principles of informed consent are described in the Code of Federal 
Regulations 21 CFR, part 50 and 45 CFR, part 46.  Once the Investigator has 
determined the patient’s eligibility for the study, the background of the proposed 
study and the benefits and risks of the procedures and study must be explained to 
the participant.  The participant must be able to comprehend the informed 
consent form and must sign it prior to performing any study specific procedures 
or prior to receiving medication.  The participant will receive a copy of the 
informed consent.  The original signed informed consent and Authorization for 
Use/Disclosure of PHI will be maintained in the participant’s research chart.  
Only those participants who sign the IRB approved informed consent prior to 
participation are eligible to be in the study.  Failure to provide written informed 
consent renders the patient ineligible for the study. 
 
7.2 
Confidentiality 
All information and data collected and/or sent to study personnel concerning 
participants or their participation in this study will be considered confidential.  
Only authorized personnel will have access to these confidential files. Authorized 
FDA personnel have the right to inspect and copy all records pertinent to this 
trial.  All data used in the analysis and reporting of this evaluation will be without 
identifiable reference to any patient. 
 
7.3 
Institutional Review 
The Principal Investigator will obtain approval for the study from IRB. All 
changes to the protocol must be reviewed and approved prior to implementation.  
The Principal Investigator will be responsible for obtaining annual IRB renewal 
through the duration of the study, or more frequently if required by the IRB. The 
study coordinator, Mr. Nicholas Evans, will maintain all regulatory documents. 
 
7.4 
Protocol Interpretation and Compliance 
The procedures defined in the protocol will be carefully reviewed by the 
Investigator and research staff prior to the time of study initiation to ensure 
appropriate interpretation and implementation.  No deviations from the protocol 
will be acceptable.  Any changes to the protocol in the form of an amendment 
must be submitted to the IRB. 
 
7.5 
Completion of Case Report Forms 
The Principal Investigator or his designee will be responsible for completing, in a 
timely manner, an eCRF for each patient who is registered to participate in this 
study.  The Principal Investigator will sign and date the indicated places on the 
eCRF.  This signature will indicate that a thorough inspection of the data therein 
has been made and will thereby certify the contents of the form. 
 
7.6 
Maintenance of Study Documentation 
It is the responsibility of the Principal Investigator, in coordination with Mr. 
Nicholas Evans and Mr. Brandon Poe, to maintain a comprehensive and 

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centralized filing system of all study-related documentation, which is suitable for 
inspection at any time by the FDA.  Elements should include: 
• 
Participant files – containing the completed CRFs, supporting source 
documentation, and the Informed Consent. 
• 
Regulatory Files – containing the protocol with all amendments and 
accountability records. 
 
7.7 
Final Study Report 
Upon completion of the study, the Principal Investigator is required to submit a 
final study summary report for the patients enrolled in the study 
 
7.8 
Record Retention 
All records, which are part of this study, will be retained for a period of two years 
following discontinuation/termination of the study. 
 
 
8.0 Study Medication/Device/Intervention/Other Procedure Details 
 
Blinding: Assessors will remain blinded to participant group allocation throughout the duration of 
the study. 
 
Assignment of Study Intervention: To ensure equivalence of baseline data, stratified 
randomization will be used to ensure equal distribution of more- and less-impaired participants 
between groups. 
 
Dosing and Treatment:  Participants will participate in a total 1x2-hour baseline testing session, 
3x1-hour MT or MT+tDCS sessions, and 1x1hour follow-up testing session over 5 consecutive 
days. MT activities will take approximately 18 minutes to complete. 
 
Identity of Medication/Device/Treatment:  tDCS will be delivered using a Soterix Medical, Inc. 
1x1 tDCS device. 
 
Unblinding Procedures: Data will remain blinded throughout participant enrollment and testing.  
Interim data analyses will not be performed for this study. Data will be unblinded by Mr. Brandon 
Poe upon completion of all evaluations for all study participants.  
 
9.0 
References 
 
1. 
National Spinal Cord Injury Statistical Center, Spinal Cord Injury (SCI): Facts and Figures at a 
Glance. 2018, University of Alabama at Birmingham: Birmingham, AL. 
2. 
Ditunno, P., et al., Who wants to walk? Preferences for recovery after SCI: a longitudinal and 
cross-sectional study. Spinal Cord, 2008. 46: p. 500-506. 
3. 
Field-Fote, E. and K. Raoch, Influence of a locomotor training approach on walking speed and 
distance in people with chronic spinal cord injury: a randomized clinical trial. . Physical Therapy, 2011. 
91: p. 48-60. 
4. 
del-Ama, A., et al., Review of hybrid exoskeletons to restore gait following spinal cord injury. 
Journal of Rehabilitation Research, 2012. 49: p. 497. 

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5. 
Gomes-Osman, J., et al., A systematic review of experimental strategies aimed at improving 
motor function after acute and chronic spinal cord injury. Journal of Neurotrauma, 2016. 33: p. 425-438. 
6. 
Duncan, P., K. Sullivan, and A. Behrman, Body-weight-supported treadmill rehabilitation after 
stroke. New England Journal of Medicine, 2011. 364: p. 2026-2036. 
7. 
Rojas Vega, S., et al., Impact of exercise on neurplasticity-related proteins in spinal cord injured 
humans. Neuroscience and Biobehavioral Reviews, 2008. 153: p. 1064-1070. 
8. 
Satton, M., et al., A single bout of moderate aerobic exercise improves motor skill acquisition. 
Plos One, 2015. 10(10): p. e0141393. 
9. 
Tillakaratne, N., et al., Use-dependent modulation of inhibitory capacity in the feline lumbar 
spinal cord. Jounral of Neuroscience, 2002. 22(8): p. 3130-3143. 
10. 
Manella, K. and E. Field-Fote, Modulatory effect of locomotor training on extensor spasticity in 
individuals with motor-incomplete spinal cord injury. Restorative Neurology & Neuroscience, 2013. 
31(5): p. 633-646. 
11. 
Cote, M., et al., Exercise modulates chloride homeostasis after spinal cord injury. Journal of 
Neuroscience, 2014. 34(27): p. 8976-8987. 
12. 
Grillner, S. and E. Ekeberg, Intrinsic function of a neuronal network - a vertebrate central 
pattern generator. Brain Research Reviews, 1998. 26(2-3): p. 184-197. 
13. 
Singh, A., et al., Role of spared pathways in locomotor recovery after body-weight-supported 
treadmill training in contused rats. Journal Neurotrauma, 2011. 28(12): p. 2405-2416. 
14. 
Thomas, S., M. Gorassini, and L. Sarah, Increases in corticospinal tract function by treadmill 
training after incomplete spinal cord injury. Journal of Neurophysiology, 2005. 94(4): p. 2844-2855. 
15. 
Manella, K., K. Roach, and E. Field-Fote, Operant conditioning to increase ankle control or 
decrease reflex excitability improves reflex modulation and walking function in chronic spinal cord 
injury. Journal Neurophysiology, 2013. 109(11): p. 2666-2679. 
16. 
Madhaven, S., K. Weber, and J. Stinear, Non-invasive brain stimulation enhances fine motor 
control of the hemiparetic ankle: implications for rehabilitation. Experimental Brain Research, 2011. 
209(1): p. 9-17. 
17. 
Sohn, M., S. Jee, and Y. Kim, Effect of transcranial direct current stimulation on postural 
stability and lower extremity strength in hemiplegic stroke patients. Annals of Rehabilitation Medicine, 
2013. 37(6): p. 759-765. 
18. 
Tanaka, S., K. Takeda, and Y. Otaka, Single session of transcranial direct current stimulation 
transiently increases knee extensor force in patients with hemiparetic stroke. Neurorehabilitation and 
Neural Repair, 2011. 25(6): p. 565-569. 
19. 
Kaski, D., et al., Improving gait and balance in patients with leukoaraiosis using transcranial 
direct current stimulation and physical training: an exploratory study. Neurorehabilitation and Neural 
Repair, 2013. 27(9): p. 864-871. 

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20. 
Benito, J., H. Kumru, and N. Murillo, Motor and gait improvements in patients with incomplete 
spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation. Topics in 
Spinal Cord Injury Rehabilitation, 2012. 18(2): p. 106-112. 
21. 
Roche, N., et al., Effects of anodal tDCS on lumbar propriospinal system in healthy subjects. 
Clinical Neurophysiology, 2012. 123(5): p. 1027-1034. 
22. 
Aree-uea, B., N. Auvichayapat, and T. Janyacharoen, Reduction of spasticity in cerebral plasy by 
anodal transcranial direct current stimulation. Journal of the Medical Assocaition of Thailand, 2014. 
97(9): p. 954-962. 
23. 
American Spinal Injury Association, International Standards for Neurological Classification of 
Spinal Cord Injury (ISNCSCI). 2015: Atlanta, GA. 
24. 
van Middendorp, J., A. Hosman, and A. Donders, A clinical prediction rule for ambulation 
outcomes after traumatic spinal cord injury: a longitudinal cohort study. Lancet, 2011. 377(9770): p. 
1004-1010. 
25. 
Kim, C., J. Eng, and M. Whittaker, Level walking and ambulatory capacity in persons with 
incomplete spinal cord injury: relationships with muscle strength. Spinal Cord, 2004. 42(3): p. 156-162. 
26. 
Wirth, B., H. van Hedel, and A. Curt, Ankle paresis in incomplete spinal cord injury: relation to 
corticospinal conductivity and ambulatory capacity. Journal of Clinical Neurophysiology, 2008. 25(4): p. 
210-217. 
27. 
Crozier, K., et al., Spinal cord injury: prognosis for ambulation based on quadriceps recovery. 
Paraplegia, 1992. 30(11): p. 762-767. 
28. 
Reis, J., H. Schambra, and L. Cohen, Noninvasive cortical stimulation enhances motor skill 
acquisition over multiple days through an effect on consolidation. Proceedings of the National Academy 
of Sciences, 2009. 106(5): p. 1590-1595. 
29. 
Tinetti, M. and L. Powell, Fear of falling and low self-efficacy: a case of independence in elderly 
persons. Journal of Gerontology, 1993. 48(Spec Issue): p. 35-38. 
30. 
Goh, H., et al., Falls and fear of falling after stroke: a case-control study. Physical Medicine and 
Rehabilitation, 2016. 
31. 
John, L., B. Cherian, and A. Babu, Postural control and fear of falling in persons with low-level 
paraplegia. Journal of Rehabilitation Research and Development, 2010. 47(5): p. 497-502. 
32. 
Dewan, N. and J. MacDermid, Fall Efficacy Scale - International (FES-I). Journal of 
Physiotherapy, 2014. 60: p. 60. 
33. 
Capaday, C., et al., Studies on the corticospinal control of human walking: response to 
transcranila magnetic stimulation of the motor cortex. Journal of Neurophysiology, 1999. 81(1): p. 129-
139. 
34. 
Schubert, M., et al., Corticospinal input in human gait: modulation of magnetically evoked motor 
responses. Experimental Brain Research, 1997. 115(2): p. 234-246. 

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35. 
Bosveld, R. and E. Field-Fote, Single-dose effects of whole body vibration on quadriceps strength 
in individuals with motor-incomplete spinal cord injury. Journal of Spinal Cord Medicine, 2015. 38(6): p. 
784-791. 
36. 
Benz, E., et al., A physiologically based clinical measure for spastic reflexes in spinal cord 
injury. Archives of Physical Medicine and Rehabilitation, 2005. 86(1): p. 52-59. 
37. 
Nitsche, M., et al., Transcranial direct current stimulation: state of the art 2008. Brain 
Stimulation, 2008. 1(3): p. 206-223. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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10.0    Appendices – Forms, Study Tools, Questionnaires, Device Manual, etc. 
 
APPENDIX A. tDCS Set-up and implementation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skill 
Note anode/cathode position per study protocol 
Ensure tDCS kit is stocked: tDCS unit, cables, rubber electrodes, spare batteries, measuring tape, sponges, saline & syringe, coban, washcloths, 
alcohol swabs 
Explain intervention to participant 
Measure and record nasion-inion distance and distance between preauricular points 
Calculate and record area for anode and cathode placement based on measurements and 10-20 EEG system 
Inspect scalp for pre-existing irritation, cuts or lesions 
Separate hair and clean underlying scalp with alcohol to reduce impedance  
Connect tDCS unit, cables and rubber electrodes 
Saturate sponges with saline (~6 ml/side) and insert rubber electrodes into sponges 
Place anode in prepared location and secure with coban 
Place cathode in prepared location and secure with coban 
Turn on tDCS unit; confirm duration, intensity and sham settings 
Start stim session; use relax button if stim is too intense for participant 
Ensure participant is comfortable throughout stimulation 
Turn off tDCS unit after session is complete (active button no longer lit) 
Remove sponges from scalp 
Inspect scalp for evidence of irritation and record observations 
Ask participant how he/she is feeling and whether he/she has any questions 
Wash saline from sponges and air dry if they are to be reused 
 

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APPENDIX B. Walking function test set-up and implementation. 
 
 
Xsens Set-up: 
A. Setup the Gaitrite hardware (10 min before subject arrives) 
1) Take the gaitrite from its assigned space in the lab, and place it in the center of the gait test area. 
2) This step requires two people, so ask for help 
3) Connect the power extension cord to the power source 
4) Connect the Gaitrite mat to the hub using the orange cable at the beginning of the mat (see picture) 
5) Connect the USB cable from the hub to the recording PC with Gaitrite software installed 
 
 
 
 
 
 
 
B. Setup the Gaitrite software and open subject session on PC 
1) Open the Gaitrite application on the recording PC. You will see a User ID field. Click the left mouse button in the field three 
times to log in. Do not type any password. 
Set-Up Checklist 
1. Charge all MTw’s using Awinda charging stations for at least 12 hours before use.  
2. Ensure that motion tracking is being set-up away from any strong magnetic fields. 
3. Turn on laptop and insert Sentinel flash drive into the USB port (this is necessary to run the MVN Studio software). 
4. Connect Awinda Wireless Station to the laptop using the Ethernet to USB cable (the Awinda Dongle can be used in place of wireless station 
but receiving range is limited). 
5. Connect power source to Allied Vision Technologies Camera and connect the camera to the laptop using the supplied Ethernet cable.  
6. From the laptop desktop, open the MVN Studio program. 
 

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• 
HAND: Using the gloves, place the left and right HAND MTw’s in the pockets located on the backside of the hands. 
• 
PELV: Using the pelvic FabriFoam strap, wrap the PELV MTw around the pelvis with the MTw positioned flat on the sacrum. 
• 
ULEG: Using the upper leg FabriFoam straps, wrap the left and right ULEG MTw’s around the thigh with the MTw’s placed on 
the lateral side at the midpoint between the hip and knee. 
• 
LLEG: Using the lower leg FabriFoam straps, wrap the left and right LLEG MTw’s around the lower leg with the MTw’s placed 
flat on the medial surface of the tibia at the midpoint between the knee and ankle. 
• 
FOOT: Using the Velcro foot pads, secure the left and right FOOT MTw’s on the middle of the bridge of the foot between the shoe 
tongue and shoelaces. Tighten the shoestrings to secure the foot pad and MTw in place. 
1. Under the MVN System tab, check the hardware status to ensure that all MTw’s have been recognized by the MVN Studio software (a green 
icon indicates a given body segment is connected; a black icon indicates a given body segment is not detected). 
2. Calibrate the system: 
• 
Have the participant stand and assume N-Pose (Neutral Pose) – standing upright on a horizontal surface with feet parallel (one foot 
width apart), face forward, and arms straight alongside the body with palms facing inwards and thumbs facing forwards. Physical 
assistance may be needed to assist the participant in this position.  
• 
When ready, under the “Calibration” tab to the left of the screen, select N-Pose icon and click the “Calibrate” and then “Start” 
buttons. 
• 
Hold the position for the time indicated on the computer, and if the result is “good” then click “accept”. If the messages “poor” or 
“fail” appear, repeat the calibration before proceeding. 
3. Position participant at the location where gait testing or other motor tasks will be performed (e.g. 10MWT, 6MWT, Agility T-test, etc.).  
4. Record a motion tracking trial by clicking on the red record button located at the top of the MVN Studio screen toolbar. 
5. When the participant completes the designated activity, click the same record button located at the top of the MVN Studio screen tollbar 
(during recording the button will be red and black).  
6. After recording, a popup dialog box will appear so that relevant notes and comments regarding the motion tracking session can be entered 
and viewed when opening the file. 
7. Save the current trial (the file name along with the date, time, and trial number will automatically be generated based on the Subject ID 
entered in Step 7). 
 
1. Under File tab, select New Recording Session. 
2. Current Configurations dialog box appears. In bottom right box next to the file directory name, enter the pre-determined Subject ID. 
3. Accept Current Configurations by selecting Ok. 
4. Turn on all MTw’s by depressing the button located next to the charging port (the LED indicator on the top of each MTw should flash 
slowly when turned on). 
5. Explain the set-up process and testing procedures to the participant. 
6. Obtain “Offline Body Dimensions” (in standing position when possible) using the Segmometer and input the results (in cm) under the Body 
Dimensions tab to the left of the screen : 
• 
Body Height: Ground to top of head when standing upright. 
• 
Foot Size: Top of shoe nose to end of the heel. 
• 
Arm Span: Top of right fingers to top of left fingers in T-space. 
• 
Hip Height: Ground to most lateral bony prominence of greater trochanter. 
• 
Knee Height: Ground to lateral epicondyle on the femoral bone. 
• 
Ankle Height: Ground to distal tip of lateral malleolus. 
• 
Hip Width: Right to left anterior superior iliac spine. 
• 
Shoulder Width: Right to left distal tip of acromion (acromial angle). 
• 
Shoe Sole Thickness: Average thickness of the sole of the used shoes. 
7. Once Body Dimensions have been entered, Save participant anthropometrics under pre-identified Subject ID (participant body dimensions 
can be re-loaded for future assessments). 
8. For full-body motion tracking, use the headband, 9 FabriFoam Velcro straps, gloves, footpads, and Lycra shirt (or giger strap or adhesive 
athletic tape) to secure MTw’s in place. Begin MTw placement for each body segment as indicated on the side of each MTw. Proceed from 
the top down as follows: 
• 
HEAD: Place the HEAD MTw in the headband pocket (adjust the headband to any comfortable position). 
• 
SHOU: Wearing the Lycra shirt, place left and right SHOU MTw’s on Velcro tabs located on the bilateral scapulae. 
• 
STERN: Wearing the Lycra shirt, place the STERN MTw in the pocket located at the sternum. MTw should be placed flat, in the 
middle of the chest. 
• 
UARM: Using the upper arm FabriFoam straps, wrap the left and right UARM MTw’s on the lateral side of the arm above the main 
thickness of the biceps. 
• 
FARM: Using the forearm FabriFoam straps, wrap the left and right FARM MTw’s above the wrist on the lateral, flat portion 
across the distal radius and ulna. 
 

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Skill 
10-Meter Walk Test  
 
Sets up 14 meter course with 2 meter marks at each end 
Gives appropriate instructions to subject 
Start timing when lead toes cross 2 meter mark 
Stops timing when lead toes cross 12 meter mark 
Records result in seconds 
Records assistive device used 
2-Minute Walk Test 
 
Ensure course is free of obstacles 
Gives appropriate instructions to subject 
Starts timing at “Go” command 
Marks distance at the end of 2 minutes 
Records distance in meters  
Records assistive device used 
 

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APPENDIX C. Berg Balance test implementation. 
 
 

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APPENDIX D. Falls Efficacy Scale-International test implementation. 
 
 

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APPENDIX E. Isometric muscle strength test set-up and implementation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Skill 
Isometric Quadriceps Strength 
 
Explains procedure & models test for the subject 
Ensures dynamometer is secured to frame 
Ensures dynamometer output is in pounds 
Positions subject so that the hip is at 90 degrees 
and knee is flexed at 60 degrees.  
The lower leg is in contact with the 
dynamometer at a point just superior to the ankle 
joint articulation. 
Subject’s legs are restrained to ensure that the 
subject is secure and hips are not used in the test. 
Once subject has been positioned, record seat 
height, bar height, and dynamometer angle. 
Give subject a “3-2-1” countdown and provide 
verbal encouragement to “Push!” and hold for 3 
seconds. 
Provide 60secs rest between MVC efforts. 
Record results after each effort and repeat 3 
times. 
Isometric Dorsiflexor Strength 
 
Explains procedure & models test for the subject 
Ensures dynamometer is secured to frame 
Ensures dynamometer output is in pounds 
Positions subject so that the hip, knee, and ankle 
are at 90 degrees with the foot fully on a step. 
The dynamometer should be in contact with the 
dorsum of the midfoot with a bias toward the 
first metatarsal. 
 

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APPENDIX F. Modified 5-Times Sit-to-Stand test set-up and implementation. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Modified 5 Times Sit-to-Stand Test 
 
Adjusts mat table height to 80% of the subject’s  leg length 
Explains procedure & models test for the subject 
Ensures that subject’s arms are not used 
Starts stopwatch on “Go” command 
Stops timing when subject sits the 5th time 
Records result as a time (seconds) 
 

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APPENDIX G. Spinal Cord Assessment Tool for SCI test implementation. 
 
 
 
 
Spinal Cord Assessment Tool for Spastic Reflexes: 
Adapted from Benz EN et al. A physiologically based clinical measure for spastic reflexes in spinal 
cord injury, Arch Phys Med Rehabil, 86: 52-9, 2005; paragraphs under "Instruments" - "SCATS: 
clonus" and "SCATS: flexor spasms" and "SCATS: extensor spasms". Used with permission from 
Elsevier Publishing. 
 
 
R 
L 
  
Clonus of the plantarflexors was quantified in response 
to a rapid passive dorsiflexion of the ankle (A). The 
ankle was dorsiflexed at an angle that triggered clonus, 
and the duration of clonic bursts was timed. An ordinal 
rating from 0 to 3 was determined by the duration of 
clonic activity where 0 is no reaction; 1 is mild, clonus 
was maintained less than 3 seconds; 2 is moderate, 
clonus persisted between 3 and 10 seconds; and 3 is 
severe, clonus persisted for more than 10 seconds. 
  
SCATS: Clonus 
0 
0 
no reaction 
1 
1 
Mild <3 secs 
2 
2 
3< Moderate <10 secs 
3 
3 
Severe > 10 secs 
  
  
SCATS: flexor spasms. 
      With the knee and hip extended to 0°, the clinician 
applied a pinprick stimulus for 1 second to the medial 
arch of the subject’s foot (B). Excursion of the big toe 
into extension, ankle dorsiflexion, and knee and hip 
flexion were visually observed for severity. The rating 
scale consisted of a score from 0 to 3, where 0 is no 
reaction to stimulus; 1 is mild, less than 10° of excursion 
in flexion at the knee and hip or extension of the great 
toe; 2 is moderate, 10° to 30° of flexion at the knee nd 
hip; and 3 is severe, 30° or greater of knee and hip 
flexion. 
0 
0 
no reaction 
1 
1 
less than 10° of excursion in 
flexion at the knee and hip or 
extension of the great toe 
2 
2 
moderate, 10° to 30° of flexion 
at the knee and hip 
3 
3 
severe, 30° or greater of knee 
and hip flexion. 
  
  
SCATS: extensor spasms 
        With the contralateral limb extended, the tested 
knee and hip were positioned at angle of 90° to 110° of 
hip and knee flexion, and then both joints were 
simultaneously extended. One hand cupped the heel 
while the other was placed on the outside of the thigh 
(C). Once a reaction was elicited, the duration of visible 
muscle contraction in the quadriceps muscle was 
measured by observing superior displacement of the 
patella. The timed scale (0–3) that was used for clonus 
was also applied to the timed extensor spasms. 
0 
0 
no reaction 
1 
1 
Mild <3 secs 
2 
2 
3secs < Moderate <10 secs 
3 
3 
Severe > 10 secs 
 

Page 33 of 37 
 
 
 
 
Version 6.0 08/27/2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
R 
L 
  
  
SCATS: Clonus 
0 
0 
no reaction 
1 
1 
Mild <3 secs 
2 
2 
3< Moderate <10 secs 
3 
3 
Severe > 10 secs 
  
  
SCATS: flexor spasms. 
0 
0 
no reaction 
1 
1 
less than 10° of excursion in flexion at the knee and hip or extension of the 
great toe 
2 
2 
moderate, 10° to 30° of flexion at the knee and hip 
3 
3 
severe, 30° or greater of knee and hip flexion. 
  
  
SCATS: extensor spasms 
0 
0 
no reaction 
1 
1 
Mild <3 secs 
2 
2 
3secs < Moderate <10 secs 
3 
3 
Severe > 10 secs 
 

Page 34 of 37 
 
 
 
 
Version 6.0 08/27/2019 
APPENDIX H. Cardiopulmonary graded exercise test (GXT). 
 
 
 
 
 
 
 
Cardiopulmonary Graded Exercise Test (GXT) 
 
 
Subject Name:                          Date:                  
 Estimated HR Max 220 – Age =  
________________  
 
 
 
 
 
 
 
 
85% Age Predicted Max HR = 
________ 
 
 
 
 
 
 
Vitals 
 
Pre Test 
Post Test 
Recovery 
Blood Pressure 
 
 
 
Heart Rate 
 
 
 
RPE 
 
 
 
 
Equipment Setup 
Machine Used 
 
Seat Setting 
 
Arm Length 
 
Back Tilt 
 
Miscellaneous  
Data Collection 
Primary  
Secondary 
Time: (minutes) 
Heart Rate 
(bpm) 
VO2 
RPE 
RER 
BP 
1:00 
 
 
 
 
 
2:00 
 
 
 
 
 
3:00 
 
 
 
 
 
4:00 
 
 
 
 
 
5:00 
 
 
 
 
 
6:00 
 
 
 
 
 
7:00 
 
 
 
 
 
8:00 
 
 
 
 
 
9:00 
 
 
 
 
 
10:00 
 
 
 
 
 
11:00 
 
 
 
 
 
12:00 
 
 
 
 
 
13:00 
 
 
 
 
 
14:00 
 
 
 
 
 
15:00 
 
 
 
 
 
Test Summary 
Time 
 
Peak VO2 
 
Peak Heart Rate 
 
Heart rate @ AT 
 
Other Notes 
 

Page 35 of 37 
 
 
 
 
Version 6.0 08/27/2019 
APPENDIX I. Brain-Derived Neurotrophic Factor (BDNF) Protocol and Checklist 
 
Equipment Checklist 
Qty 
Completed? 
(Y/ N) 
Date 
Employee’s 
Initials 
Supervisor’s 
Initials 
Serum separator vacutainer tubes 
 
 
 
 
 
PCR tube strips 
 
 
 
 
 
Transportation container (frozen shipper – no cost) 
 
 
 
 
 
Dry ice 
 
 
 
 
 
biosensis Mature BDNF Rapid ELISA Kit (96 well 
microplate) 
12 x 8 
wells 
 
 
 
 
Assay diluent A (1x)  
2 x 25 
mL 
 
 
 
 
Recombinant human mature BDNF standard 
2 x 1000 
pg 
 
 
 
 
Quality control sample (QC) 
2 vials 
 
 
 
 
Mature BDNF detection antibody (100x) 
1 x 110 
μL 
 
 
 
 
Streptavidin-HRP (100x) – do not freeze 
1 x 110 
μL 
 
 
 
 
Wash buffer (10x) 
1 x 33 
mL 
 
 
 
 
TMB substrate (1x) 
1 x 11 
mL 
 
 
 
 
TMB stop solution (1x) 
1 x 11 
mL 
 
 
 
 
Plate sealer 
1 
 
 
 
 
Pipettes (single channel) 
10-1000 
μL 
 
 
 
 
Plate shaker 
 
 
 
 
 
Microplate reader (absorbance at 450 nm) 
 
 
 
 
 
 
*Notes: To prevent sample variation, strict adherence to consistent sample preparation 
procedures among samples is necessary. 
Serum Sample Collection & Preparation 
Completed? 
(Y/ N) 
Date 
Employee’s 
Initials 
Supervisor’s 
Initials 
1. Serial venous blood draws will be collected on Day 1 
(Baseline), before and after training on Day 2 (Intervention), 
and on Day 5 (Persistence) (i.e. 4 total samples per 
participant). 
 
 
 
 
2. Butterfly catheter placed in the participant’s upper 
extremity. 
 
 
 
 
3. Samples collected in a 10mL serum separator vacutainer 
tube. 
 
 
 
 
4. Allow sample to clot for 1 hour at room temperature 
(research work room) 
 
 
 
 
5. Centrifuge at 1000g for 15 minutes. 
 
 
 
 
6. Prepare aliquots of 200μL in thin wall 0.2mL PCR tube 
strips. 
 
 
 
 

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Version 6.0 08/27/2019 
7. Store aliquots at -20°C until frozen samples are transported 
to Ga Tech within 24 hours.  
 
 
 
 
8. Store frozen samples at -80°C. 
 
 
 
 
9. Prior to beginning assay procedures, allow samples to 
slowly thaw. (thaw time?) 
 
 
 
 
10. Working pH of a sample should be near neutral (pH 6.8-7.5) 
– adjust with mild acid or base as needed. 
 
 
 
 
11. A minimum dilution of 1/50 to 1/1000 with Assay Diluent A 
is required.  
 
 
 
 
 
 
Preparation of Mature BDNF Standard 
Completed? 
(Y/ N) 
Date 
Employee’s 
Initials 
Supervisor’s 
Initials 
12. See biosensis manufacturer specifications  
 
 
 
 
 
Other Reagents and Buffer Preparation 
Completed? 
(Y/ N) 
Date 
Employee’s 
Initials 
Supervisor’s 
Initials 
13. Quality Control (QC) sample 
 
 
 
 
 
Assay Procedure 
Completed? 
(Y/ N) 
Date 
Employee’s 
Initials 
Supervisor’s 
Initials 
14. All steps are performed at room temperature (20-25°C, 70-
75°F) 
 
 
 
 
15. Add 100μL of diluted mature BDNF standards, QC sample, 
samples and blank (sample diluent only) to the pre-coated 
microplate wells 
 
 
 
 
16. Include sample-specific negative and positive control 
sample in the assay procedure (?). 
 
 
 
 
17. Seal the plate (plate sealer or parafilm). 
 
 
 
 
18. Incubate the plate on a shaker for 45 minutes (140rpm; 
0.351 G*). 
 
 
 
 
19. Discard the solution inside the wells. 
 
 
 
 
20. Perform 5 washes with 1x wash buffer (200μL per well) – 
see technical hints for details 
 
 
 
 
21. Add 100μL of the detection antibody (1x) into each well. 
 
 
 
 
22. Seal the plate. 
 
 
 
 
23. Incubate the plate on a shaker for 30minutes (140rpm; 0.451 
G*). 
 
 
 
 
24. Discard the solution inside the wells and wash as described 
in step 22. 
 
 
 
 
25. Add 100μL of the 1x streptavidin-HRP conjugate into each 
well. 
 
 
 
 
26. Seal the plate. 
 
 
 
 
27. Incubate the plate on a shaker for 30minutes (140rpm; 0.451 
G*). 
 
 
 
 
28. Discard the solution inside the wells and wash as described 
in step 22. 
 
 
 
 
29. Add 100μL of TMB into each well. 
 
 
 
 

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Version 6.0 08/27/2019 
30. Incubate plate at room temperature for 4-8 minutes without 
shaking in the dark. 
 
 
 
 
31. Stop the reaction by adding 100μL of the stop solution into 
each well. 
 
 
 
 
32. Visible blue color will change to yellow. 
 
 
 
 
33. Read the absorbance at 450nm on a plate reader (read within 
5minutes of adding stop solution and no longer than 
30minutes).