Improving Motor Function After Spinal Cord Injury

Study Overview
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Brief Summary
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The goals of this study are to examine the physiology of Central Nervous System pathways contributing to the control of upper and lower extremity movements after SCI, and to promote the recovery of extremity movements by using non-invasive brain stimulation and motor training.

Detailed Description
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This study will consist of electromyography (surface and intramuscular), peripheral nerve stimulation, and transcranial magnetic stimulation, electrical stimulation, of the hand, arm, leg, and foot representation of the primary motor cortex, as well as MRI scans of the brain. The investigators will examine the physiological measurements of upper and lower extremity muscles (such as in the first dorsal interosseous (FDI), biceps brachii (BIC), anterior deltoid (AD), tibialis anterior (TA), hamstring (HAMS) and quadriceps (QUAD)). This study may occur at the Miami Project to cure Paralysis at the University of Miami. The investigators will include subjects between the ages of 18 and 85, both healthy controls and individuals with chronic spinal cord injuries that occurred at least 6 months prior to recruitment. Both healthy controls and those with spinal cord injuries will be able to perform small hand and arm movements and small leg and foot movements. The primary outcome measures of this study are muscle responses to stimulation with magnetic pulses using TMS and electrical stimulation of a peripheral nerve in the arm or leg. The investigators propose to enhance the recovery of motor function by using new protocols of high frequency non-invasive repetitive TMS (rTMS) and motor training. Repetitive TMS will be used during hand, arm, leg and foot movements in a task-dependent manner to induce cortical plasticity and enhance voluntary output of the muscles associated with those movements. Second, rTMS will be applied in a task-dependent manner during a visuo-motor training task that also involves movements of the hands, arms, legs or feet.

Official Title
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Enhancement of Hand Motor Function After Cervical Spinal Cord Injury

Conditions
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Spinal Cord Injury

Intervention / Treatment
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* Device: rTMS
* Device: Sham rTMS
* Other: Training
* Other: Motor Task


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male and female Veterans and non Veterans with spinal cord injury at least 6 months after injury was sustained. The investigators also plan to enroll control subjects who do not have any history of spinal cord injury. Participants who are unimpaired healthy controls: Male and females between ages 18-85 years Right handed Able to complete precision grips with both hands Able to complete full wrist flexion-extension bilaterally Able to walk unassisted Able to complete full ankle flexion-extension bilaterally Participants who have had a spinal cord injury: Male and females between ages 18-85 years Chronic SCI ( 6 months of injury) Spinal Cord injury at or above L5 The ability to produce a visible precision grip force with one hand Individuals who have the ability to pick up a small object (large paperclip) from a table independently Able to perform some small wrist flexion and extension (measured by a goniometer) The ability to perform a small visible contraction with dorsiflexor and hip flexor muscles No subjects will be excluded based on their race, religion, ethnicity, gender or HIV status. Exclusion Criteria: Exclusion criteria for enrollment For SCI and Healthy Control Subjects (for stimulation): Uncontrolled medical problems including pulmonary, cardiovascular or orthopedic disease Any debilitating disease prior to the SCI that caused exercise intolerance Premorbid, ongoing major depression or psychosis, altered cognitive status History of head injury or stroke Metal plate in skull History of seizures Receiving drugs acting primarily on the central nervous system, which lower the seizure threshold (see appendix 2) Pregnant females Ongoing cord compression or a syrinx in the spinal cord or who suffer from a spinal cord disease such as spinal stenosis, spina bifida, MS, or herniated cervical disk Individuals with scalp shrapnel, cochlear implants, or aneurysm clips.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Motor task+ Magnetic stimulation<br>Participants will be asked to complete a precision grip with the index and thumb finger at the same time as flexing or extending the wrist. magnetic stimulation to the brain will be administered and measurements will be taken during movement. | Device: rTMS<br>* small magnetic pulses will be given to the brain in a non invasive manner.<br>Device: Sham rTMS<br>* sham or fake stimulation (TMS or rTMS) will be given to the brain in a non invasive manner<br>Other: Motor Task<br>* participants will be asked to perform specific motor tasks or movements with their fingers, hands, arms or legs.<br>|
| Active Comparator: rTMS/sham rTMS<br>Participant will be randomly assigned to one of 3 groups: repetitive transcranial magnetic stimulation (rTMS), sham (fake) rTMS, or sham (fake) rTMS over control brain area will be administered to the brain. the stimulation will be targeting finger and wrist muscles during movement. | Device: rTMS<br>* small magnetic pulses will be given to the brain in a non invasive manner.<br>Device: Sham rTMS<br>* sham or fake stimulation (TMS or rTMS) will be given to the brain in a non invasive manner<br>|
| Active Comparator: Training + rTMS/ Sham rTMS<br>Participants will be asked to follow a target line on the computer as accurately as possible while performing precision grips or foot movement . Magnetic stimulation will be given during rest and movement. | Device: rTMS<br>* small magnetic pulses will be given to the brain in a non invasive manner.<br>Device: Sham rTMS<br>* sham or fake stimulation (TMS or rTMS) will be given to the brain in a non invasive manner<br>Other: Training<br>* at the direction of the researcher the participant will be instructed to do repetitive motor movements with their arm, hand or leg. this is called training<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Physiology Measurements Before and After rTMS/Sham rTMS Protocol- Changes in Amplitude of Motor Evoked Potential (MEP) From TMS | For Wrist flexion and precision grip + rTMS/Sham rTMS and Wrist extension and precision grip + rTMS/Sham rTMS we measured the changes in the MEPs before the intervention(rTMS/Sham rTMS) at minute 0, 10, 30, and 60 and then again after at minute 0, 10, 30, and 60. The information below is separated first by wrist flexion or extension, then by study visit (rTMS or Sham rTMS), and finally by subject characteristic (SCI or control). This study is a crossover design, what that means is subjects (SCI and Controls) will participate in both sessions (rTMS and Sham rTMS). For rTMS/Sham rTMS/Sham rTMS over control brain area we measured the changes in the MEPs at minute 0, 10, 30, and 60.The information for this arm is separated by study visit: Session 1 is rTMS, Session 2 is Sham rTMS, and Session 3 is Sham rTMS over control brain area. For Training + rTMS and Training + Sham rTMS we measured the changes in the MEPs at baseline, post 5 training sessions, and post all training sessions. | Post rTMS, Sham rTMS, and Sham rTMS over control brain for all sessions at minute 0, 10, 30, and 60 | 
| Electromyography (EMG) | For rTMS/Sham rTMS/Sham rTMS over control brain area we measured voluntary output in hand muscles using EMG before and after the stimulation.The information for this arm is separated by study visit: Session 1 is rTMS, Session 2 is Sham rTMS, and Session 3 is Sham rTMS over control brain area. | Before and After the stimulation during each 2-hour session (rTMS/Sham rTMS/Sham rTMS over control brain area) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The Jebsen Taylor Hand Function Test (JTT) | The JTT is a standardized test of several major aspects of hand function using simulated activities of daily living (writing, picking up small objects, picking up heavy objects etc.). The time taken to perform simulated activities of daily living is assessed. Lesser time to perform the activities would be considered a better outcome. | The JTT was measured at Baseline, Post 5 training sessions, and Post all training sessions at each 2-hour session. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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spinal cord injury, neural control, motor function, hand movement