Upper Limb-based Movement Priming for Lower Limb Neuroplasticity & Motor Recovery in Stroke

Study Overview
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Brief Summary
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The goal of this clinical trial is to to determine the effect of movement-based priming using the upper limbs on lower limb neuroplasticity and behaviors in chronic stroke. The main questions we aim to answer are: What are the acute effect of UL-priming on lower limb neuroplasticity and motor behaviors in persons with stroke compared to other priming modalities? What are the time effects of UL-priming on neuroplasticity and motor behavior in individuals with stroke? In this cross over study, participants will be involved in three priming sessions involving - UL-priming using rhythmic, bilateral priming involving the movement of at least one major joint in the upper limbs. AND - Sham priming using auditory stimulation (1 Hz metronome). AND - Stimulation-based priming using anodal transcranial direct current stimulation (tDCS). OR - Lower-limb movement-based priming using aerobic exercise on a treadmill or recumbent stepper. Researchers will compare outcome measures between the different priming sessions.

Official Title
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Upper Limb-based Movement Priming for Lower Limb Neuroplasticity & Motor Recovery in Stroke

Conditions
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Stroke

Intervention / Treatment
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* Other: Upper limb-based movement priming (UL-priming)
* Other: Stimulation-based priming (Stim priming)
* Other: Lower limb-based movement priming (LL-priming)
* Other: Sham priming


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Single, monohemispheric stroke Chronic stroke (> 6 months prior) Residual hemiparetic gait deficits (e.g., abnormal gait pattern) Minimum score of stage 2 on the Chedoke Arm Impairment Scale which includes stage 2, task 3 (facilitated elbow flexion) as one of the stage 2 tasks. Exclusion Criteria: Use of anti-spasticity medications Existence of other neurological disorders Have brainstem or cerebellar lesions. Score of ≥2 on the Modified Ashworth Scale. MMSE score of <21, to ensure they will follow instructions. Non-English-speaking individuals Bone, joint or soft tissue injury Dizziness or angina during physical activity Uncontrolled medical conditions (such as uncontrolled hypertension, untreated cardiac disease, or untreated pulmonary disease) Failure to pass the Physical Activity Readiness Questionnaire (PAR-Q) TMS exclusion criteria Previous adverse reaction to TMS Skull abnormalities or fractures Concussion within the prior 6 months Unexplained, recurring headaches Implanted cardiac pacemaker Metal implants in the head or face History of seizures or epilepsy Use of medications that could alter cortical excitability or increase risk of seizure (e.g., antidepressants, antipsychotics, anxiolytics, anticonvulsants) Current pregnancy tDCS exclusion criteria Skin hypersensitivity History of contact dermatitis History of allodynia and/or hyperalgesia Any other skin or scalp condition that could be aggravated by tDCS Previous adverse reactions to tDCS

Ages Eligible for Study
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Minimum Age: 40 Years
Maximum Age: 90 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

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: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Upper limb-based movement priming (UL-priming)<br>The upper limb priming task will include rhythmic, bilateral priming involving the movement of at least one major joint in the upper limbs (shoulder, elbow, wrist). | Other: Upper limb-based movement priming (UL-priming)<br>* Repetitive upper limb movements administered to the beat of a metronome.<br>|
| Active Comparator: Stimulation-based priming (Stim priming)<br>Participants will receive facilitatory transcranial direct current stimulation (tDCS) through a constant current stimulator. | Other: Stimulation-based priming (Stim priming)<br>* Noninvasive brain stimulation.<br>|
| Active Comparator: Lower limb-based movement priming (LL-priming)<br>Participants will perform high-intensity interval-based aerobic exercise on a treadmill or recumbent stepper. | Other: Lower limb-based movement priming (LL-priming)<br>* Aerobic exercise using a treadmill or recumbent stepper.<br>|
| Sham Comparator: Sham priming<br>Participants will listen to a 1 Hz metronome for 20 minutes as a form of auditory stimulation during the sham priming session. | Other: Sham priming<br>* Auditory stimulation.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Corticomotor excitability using transcranial magnetic stimulation (TMS) | Single-pulse transcranial magnetic stimulation (TMS) will be used to assess the corticomotor excitability from the tibialis anterior muscles. | Change from baseline to immediately after priming, to 30 minutes after priming, and to 60 minutes after priming. | 
| Spinal H-reflex excitability using peripheral nerve stimulation (PNS) | Peripheral nerve stimulation (PNS) will be used to assess the H reflexes excitability from the soles muscles. | Change from baseline to immediately after priming, to 30 minutes after priming, and to 60 minutes after priming. | 
| Motor control | Motor control will be assessed by making participants track a computer-generated sinusoidal target during an ankle tracking task with ankle dorsiflexion and plantarflexion in a custom-built ankle-tracking device. | Change from baseline to immediately after priming, to 30 minutes after priming, and to 60 minutes after priming. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Gait speed | Self-selected and fastest gait speed will be measured as the average of 3 trials of the 10-meter walk test (10MWT). | Change from baseline to immediately after priming, to 30 minutes after priming, and to 60 minutes after priming. | 
| Muscle strength | An estimate of maximum ankle muscle force will be obtained for three trials of dorsiflexion and plantarflexion contractions using a force transducer. | Change from baseline to immediately after priming, to 30 minutes after priming, and to 60 minutes after priming. |