Linking Brain to Behaviour Research in SCI
Condition: Cervical Spinal Cord Injury
MeSH terms: Spinal Cord Injuries
Study type: Interventional

Summary: 
      Introduction In recent years, client-centred and task-oriented training have emerged as
      important methods in rehabilitation including the rehabilitation of persons with spinal cord
      injury (SCI). The task-oriented intervention focuses on resolving, reducing and preventing
      impairment, developing effective task-specific strategies and adapting functional
      goal-oriented strategies to changing environmental conditions. Currently, task-specific
      training is mainly achieved by constant practice (i.e. repeating the task without variation)
      and is reported to improve performance of the trained task, but to have a negative impact on
      untrained tasks. Practice variability, however, is reported being advantageous to transfer
      training results into daily live. This paradox poses challenges in clinical practice, where
      task-specific training is essential to deliver client-centred training in order to focus on
      the patients' specific individual goals, but practice variability is important to be able to
      transfer the learned task into daily practice. Questions regarding the effective elements
      within rehabilitative interventions and the exact mechanisms behind the cerebral changes they
      may induce, remain. These questions require further research, for which ultra-high field fMRI
      techniques will be used. Furthermore, compensation of muscle function loss (i.e. the
      development of new muscle synergies) plays an important role in the improvement of skill
      performance in cervical SCI. Surface EMG allows to study the changes in muscle coordination,
      parallel to the changes at cerebral level.

      Aims This study aims to

        1. investigate which basic neural mechanisms of motor learning underlie functional recovery
           of arm hand skilled performance during client-centred task-oriented training of the
           upper limb in patients with cervical spinal cord injury and

        2. investigate the contribution of 'practice variability' in contrast to 'constant
           practice' on arm-hand skilled performance, motor control and neural changes.

      Study design This study features a multiple single-case experimental design (A-B-C design)
      with baseline (phase A) (6 weeks), intervention B (phase B) (3 weeks) and intervention C
      (phase C) (3 weeks). Intervention B will contain the 'practice variability' component.
      Intervention C will feature the 'constant practice' component. The order of phase B and C
      will be randomly assigned to participants. Four measurements during baseline and after each
      intervention phase (B and C) will be performed, thus producing a time series, per measure,
      for each patient. Also, meta-analyses on the pooled single-case data will be performed.

      Setting/population Six patients with a cervical SCI (complete and incomplete) will be
      recruited from the Spinal cord unit of Adelante Rehabilitation Centre in the (sub)acute
      phase.

      Intervention After therapy as usual (intervention A), the Task-oriented Client-centred Upper
      Extremity Skill Training (ToCUEST) module (Spooren et al., 2011) will be provided. In this
      program individual goals will be extracted using the Canadian Occupational Performance
      Measure(COPM) and the training program is based on a task-analysis and uses principles of
      training physiology and motor learning. Intervention B will consist of the ToCUEST program,
      including the component 'practice variability' (ToCUEST variability). Intervention C will
      consist of a modified ToCUEST program in which the component 'practice variability' will be
      replaced by 'constant practice' (ToCUEST constant) in order to evaluate the contribution of
      these components. Intervention A' will be therapy as usual.

      Measurements Measurements will be taken at the level of activities (arm hand skilled
      performance, i.e. Van Lieshout Test, Spinal Cord Independence Measure, Goal Attainment Scale)
      and body function (Upper Extremity Motor Score, Graded Redefined Assessment of Strength
      Sensibility and Prehension Test, Surface EMG), and at cerebral level, i.e. neural activity
      changes (by means of ultra-high field fMRI).

      The fMRI measurements will be taken before and after each intervention B and C in 4 patients
      (2 with complete and 2 with incomplete lesion).

      Data-analyses Baseline data stability and any baseline trends regarding the outcome measures
      at body function level and activity level will be assessed. To control for, e.g., spontaneous
      recovery effects, baseline data (phase A) will be used in a computer-based detrending model.
      For the meta-analyses, mean data per outcome measure, per phase, per subject will be pooled
      and subsequently analysed using non-parametric statistics, i.e. Friedman analyses and
      Wilcoxon tests.
    


Intervention name(s): ToCUEST featuring a 'variable practice' approach.; ToCUEST featuring a 'constant practice' approach.
Intervention type(s): Other; Other
Intervention description(s): Intervention Variable practice: The ToCUEST (Task-Oriented Client-centred Upper Extremity Skill Training) module [17] will be given to the participants, in which individual goals will be extracted using the COPM (Canadian Occupational Performance Measure). The training program will start with a task analysis and is based on principles of training physiology and motor learning, including variability practice, random practice, distribution based practice, feedback, whole learning. A detailed description of the ToCUEST module is given in Spooren et al. [17]. Intervention B will be called 'ToCUEST variability' in the present project.; Intervention Constant practice: In order to evaluate the contribution of the component 'variability practice' in contrast with 'constant practice' the participants will be offered the modified ToCUEST ('ToCUEST constant') module in which the component 'variability practice' is replaced by 'constant practice'.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: spinal cord injury; upper extremity; skill performance; motor learning