Clinical trial NCT03887481: Targeting Language-specific and Executive-control Networks With Transcranial Direct Current Stimulation in Logopenic Variant PPA
Official title: Targeting Language-specific and Executive-control Networks With Transcranial Direct Current Stimulation in Aphasic AD (Logopenic Variant PPA)
Study type: INTERVENTIONAL
Overall status: RECRUITING
Phase: NA
Conditions: Logopenic Progressive Aphasia
Primary Progressive Aphasia
Keywords: transcranial direct current stimulation (tDCS)
neurodegeneration
verbal short-term memory
non-fluent variant
logopenic variant
primary progressive aphasia
Lead sponsor: Johns Hopkins University
Sponsor class: OTHER
Collaborators: name: National Institute on Aging (NIA)
First posted: 2019-03-25
Enrollment: 60
Sex: ALL
Minimum age (years): 50
Maximum age (years): 80
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: CROSSOVER
Intervention model description: This is a crossover design of active HD-tDCS + Language/Cognitive Intervention that crossovers to Sham + Language/Cognitive Intervention in Arm 1 and Sham + Language/Cognitive Intervention that crossovers to active HD-tDCS + Language/Cognitive Intervention in Arm 2.
Primary purpose: TREATMENT

Brief summary: AD afflicts over 5.5. million Americans and is one of the most expensive diseases worldwide. In AD the variant in which language functions are most affected are referred to as 'logopenic variant Primary Progressive Aphasia' (lvPPA). Language deficits dramatically impair communication and quality of life for both patients and caregivers. PPA usually has an early onset (50-65 years of age), detrimentally affecting work and family life. Studies have identified verbal short-term memory/working memory (vSTM/WM) as a primary deficit and cause of language impairment. In the first cycle of this award, the investigators asked the question of whether language therapy effects could be augmented by electrical stimulation. The investigators conducted the largest to-date randomized, double-blind, sham-controlled, crossover, clinical trial to determine the effects of transcranial direct current stimulation (tDCS) in PPA. The investigators found that tDCS over the left inferior frontal gyrus (L_IFG), one of the major language hubs in the brain, significantly enhanced the effects of a written naming and spelling intervention. In addition, findings demonstrated that tDCS modulates functional connectivity between the stimulated area and other networks (e.g. functionally and structurally connected areas), and that tDCS modulates the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). In terms of tDCS, the investigators have been identified several predictors to determine the beneficience of tDCS including (a) PPA variant, (b) initial performance on cognitive/language tasks, particularly vSTM/WM, and (c) initial white-matter integrity and structure. These findings support the notion that tDCS benefits generalize beyond the treatment tasks and has led to the important question of the present study: How can we implement treatments to product benefits that maximally generalize to untrained but vital language/cognitive functions.

To address the above question, the investigators will test recent neuroplasticity theories that claim that the benefits of neuromodulation to language-specific areas generalize to other language functions within the language network, while neuromodulation of a domain-general/multiple-demands area generalizes to both domain-general, executive and language functions. The two areas to be stimulated will be the supramarginal gyrus (SMG) and left dorsolateral prefrontal cortex (DLPFC) respectively. The left supramarginal gyrus (L_SMG) in particular, specializes in phonological processing, namely phonological verbal short-term memory (vSTM), i.e., the ability to temporarily store phonological (and graphemic) information in order. The domain of vSTM affects many language tasks (repetition, naming, syntax), which makes it an ideal treatment target and the L_SMG an ideal stimulation target, since generalization of tDCS effects to other language tasks is driven by the function (computation) of the stimulated area. By testing a fundamental principle of neuromodulation in a devastating neurodegenerative disorder, the investigators will significantly advance the field of neurorehabilitation in early-onset dementias.

Aim 1: To determine whether vSTM/WM behavioral therapy combined with high definition (HD)-tDCS over the L_SMG will induce more generalization to language-specific tasks than to executive tasks, whereas stimulation over the LDPFC will induce equivalent generalization to both executive and language-specific tasks.

Aim 2: To understand the mechanism of tDCS by measuring tDCS-induced changes in network functional connectivity (FC) and GABA in the LSMG and LDPFC. The investigators will carry out resting-state functional magnetic resonance imaging (rsfMRI), (MPRAGE), diffusion-weighted imaging (DWI), perfusion imaging (pCASL), and magnetic resonance spectroscopy (MRS), before, after, and 3-months post-intervention.

Aim 3: To identify the neural, cognitive, physiological, clinical and demographic characteristics (biomarkers) that predict sham, tDCS, and tDCS vs. sham effects on vSTM and related language tasks in PPA. The investigators will evaluate neural (functional and structural connectivity, cortical volume, neuropeptides, and perfusion), cognitive (memory, attention, executive) and language functions, clinical (severity), physiological (sleep), and demographic (age, gender) characteristics, and the investigators will analyze the effects on vSTM and other language/cognitive outcomes immediately after intervention and at 3 months post-intervention.

Detailed description: This proposal will extend the investigators' previous award, which provided the first evidence from a clinical trial (double-blind, sham-controlled, crossover), on the beneficial effects of transcranial direct current stimulation (tDCS) over the left inferior frontal gyrus (L_IFG) in primary progressive aphasia (PPA), a debilitating neurodegenerative disorder affecting primarily language functions. The investigators' previous studies, although it established the augmentative effects of tDCS in PPA and shed light on its possible mechanisms, the investigators also revealed a fundamental gap in the investigators' knowledge, namely the effect different tDCS effects In this present study, the investigators will directly address this knowledge gap by stimulating two areas of atrophy in PPA, the parietal cortex, the epicenter of vSTM/WM within the language network, and the frontal cortex, a major executive and multi-domain area, to test the tDCS effects in PPA, uncover the mechanisms, and estimate tDCS predictors.

Eligibility criteria: Inclusion Criteria:

* Must be between 50-80 years of age.
* Must be right-handed.
* Must be proficient in English.
* Must have a minimum of high-school education.
* Must be diagnosed with Primary Progressive Aphasia (PPA) or dementia.
* Participants will be diagnosed with PPA or with any of the PPA variants in specialized or early dementias clinics at Johns Hopkins University or other specialized centers in the US based on the current consensus criteria.
* Healthy age- and education-matched controls: The investigators will include 30 healthy age- and education-matched controls, usually spouses, to maximize similarity in terms of other demographic or life-style factors that contribute to language and cognitive performance.

Exclusion Criteria:

* People with previous neurological disease including vascular dementia (e.g., stroke, developmental dyslexia, dysgraphia or attentional deficit).
* People with uncorrected hearing loss
* People with uncorrected visual acuity loss.
* People with advanced dementia or severe language impairments: Mini Mental State -Examination (MMSE)\<18, or Montreal Cognitive Assessment (MOCA)\<15, or language Frontotemporal Dementia specific - Clinical Dementia Rating (FTD-CDR)\<=2.
* Left handed individuals.
* People with pre-existing psychiatric disorders such as behavioral disturbances, severe depression, or schizophrenia that do not allow these people to comply or follow the study schedule and requirements such as repeated evaluation and therapy.

Exclusion Criteria for MRI Participation:

* People with severe claustrophobia.
* People with cardiac pacemakers or ferromagnetic implants.
* Pregnant women.

Primary outcomes:
measure: Change in percent accuracy on word repetition (no delay) assessed by Temple Assessment of Language and Short-Term Memory in Aphasia (TALSA) Test 3
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in percent accuracy on word repetition (with 5-sec delay) assessed by TALSA Test 3
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in percent accuracy on word span assessed by TALSA Test 14
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
Secondary outcomes:
measure: Change in TALSA sentence repetition (Test 7) score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in National Alzheimer's Coordinating Center's (NACC) sentence repetition score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in digit span forward score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in visual rhyming score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in Northwestern Anagram Test (NAT) score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in NAVS - Argument Structure Production Test (ASPT) score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in spelling of non-words to dictation score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in Apraxia Battery of Adults-Second Edition (ABA-2) score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in spelling of words to dictation score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in NAVS - Sentence Comprehension Test score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in Subject-Relative, Object-Relative, Active Passive (SOAP): Test of Syntactic Complexity score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in Boston Naming Test (Short-Version) score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in oral naming of action as assessed by Hopkins Assessment of Naming Actions (HANA)
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in category fluency score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in content & efficiency of connected speech
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in N-back (2-back) word score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in digit span backward score
timeFrame: Before intervention, immediately after intervention, 1 month post intervention, 3 months post intervention
measure: Change in functional connectivity of select brain regions (z-correlations)
timeFrame: Before intervention, immediately after intervention, 3 months post intervention
measure: Change in Gamma-Aminobutyric Acid (GABA) concentration at stimulated site
timeFrame: Before intervention, immediately after intervention, 3 months post intervention
Other outcomes:
Locations:
city: Baltimore
country: United States
facility: Johns Hopkins Hospital
state: Maryland
Study officials:
affiliation: Johns Hopkins University
name: Kyrana Tsapkini, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Tsapkini K, Frangakis C, Gomez Y, Davis C, Hillis AE. Augmentation of spelling therapy with transcranial direct current stimulation in primary progressive aphasia: Preliminary results and challenges. Aphasiology. 2014;28(8-9):1112-1130. doi: 10.1080/02687038.2014.930410.
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citation: Riello M, Faria AV, Ficek B, Webster K, Onyike CU, Desmond J, Frangakis C, Tsapkini K. The Role of Language Severity and Education in Explaining Performance on Object and Action Naming in Primary Progressive Aphasia. Front Aging Neurosci. 2018 Oct 30;10:346. doi: 10.3389/fnagi.2018.00346. eCollection 2018.